Common use of Prior Authorization Requirement Clause in Contracts

Prior Authorization Requirement. All transplant procedures must be Prior Authorized for type of transplant and be Medically Necessary and not Experimental or Investigational according to criteria established by Alliant. To Prior Authorize, call (000) 000-0000. The Prior Authorization requirements are a part of the benefit administration of the Contract and are not a treatment recommendation. The actual course of medical treatment the Member chooses remains strictly a matter between the Member and his or her Physician. Your Physician must submit a complete medical history, including current diagnosis and name of the surgeon who will perform the transplant. The surgery must be performed at an Alliant-approved Transplant Center. The donor, donor recipient, and the transplant surgery must meet required medical selection criteria as defined by Alliant. If the transplant involves a living donor, benefits are as follows: • If a Member receives a transplant and the donor is also covered under this Contract, payment for the Member and the donor will be made under each Member’s Coverage. • If the donor is not covered under this Contract, payment for the Member and the donor will be made under this Contract but will be limited by any payment which might be made under any other hospitalization coverage plan. • If the Member is the donor and the recipient is not covered under this Contract, payment for the Member will be made under this Contract limited by any payment which might be made by the recipient’s hospitalization coverage with another company. No payment will be made under this Contract for the recipient. Please see the Limitations and Exclusions section for Non-Covered Services. Covered Services rendered at Urgent Care Centers are covered as outlined in the Summary of Benefits and Coverage. Urgent Care means any medical care or treatment of a medical condition that (A) could seriously jeopardize your life or health or your ability to regain maximum function or (B) in the opinion of the attending Provider, would subject you to severe pain that cannot be adequately managed without care or treatment. Treatment of an Urgent Care medical problem is not life threatening and does not require use of an emergency room at a Hospital; and is not considered an emergency. This Plan uses a Pharmacy Benefits Manager (PBM) for the administration of out-patient prescription drug benefits. Magellan Rx Management is the PBM for Alliant Health Plans. For the most up-to-date information about your Prescription Benefit Program, call Magellan Rx Customer Service at (000) 000-0000. The Magellan Rx pharmacy network includes local and retail pharmacies throughout the United States. Members may obtain prescription drug and pharmacy assistance by calling Magellan Rx Customer Service at (000) 000-0000. The Plan will provide coverage for drugs, supplies, supplements and administration of a drug (if such services would not otherwise be excluded from coverage) when prescribed by a licensed and qualified Provider and obtained at a participating pharmacy. The Plan uses a Drug Formulary, which is a list of Prescription Drugs that are covered by the Plan. The Drug Formulary includes brand-name and generic medications that have undergone a careful review by a committee of practicing physicians and pharmacists. This committee reviews new and existing medications for safety and efficacy, and decides which medications provide quality treatment at the best value. While the Drug Formulary is intended to provide comprehensive coverage of your prescription medication needs, there are some products that are not covered or have limited availability. For medications that are not on the formulary or are not covered by your prescription benefit program, talk to your physician about alternative medications. If you have questions regarding the Drug Formulary or regarding your Prescription Drug Plan, call Magellan Rx Customer Service at (000) 000-0000 or visit our website at XxxxxxxXxxxx.xxx to view the Drug Formulary. Additional information regarding Prescription Drug limitations and exclusions can be found in the Exclusions section of this Certificate. Your benefit design as shown in the Summary of Benefits and Coverage will determine the Copayment or Coinsurance of your Prescription Drug program for preferred formulary drugs and non-preferred drugs that are listed on the Drug Formulary. For prescription drugs and diabetic supplies rendered by a pharmacy, the MAC is the amount determined by us using Prescription Drug cost information provided by the PBM. At the time the prescription is dispensed; present your Identification Card at the in-network pharmacy. The In-Network pharmacy will complete and submit the claim for you. If you do not go to an In-Network pharmacy, you will need to submit the itemized xxxx to be processed.

Prior Authorization Requirement. All transplant procedures must be Prior Authorized for type of transplant and be Medically Necessary and not Experimental or Investigational according to criteria established by Alliant. To Prior Authorize, call (000) 000-0000. The Prior Authorization requirements are a part of the benefit administration of the Contract and are not a treatment recommendation. The actual course of medical treatment the Member chooses remains strictly a matter between the Member and his or her Physician. Your Physician must submit a complete medical history, including current diagnosis and name of the surgeon who will perform the transplant. The surgery must be performed at an Alliant-approved Transplant Center. The donor, donor recipient, and the transplant surgery must meet required medical selection criteria as defined by Alliant. If the transplant involves a living donor, benefits are as follows: • If a Member receives a transplant and the donor is also covered under this Contract, payment for the Member and the donor will be made under each Member’s Coverage. • If the donor is not covered under this Contract, payment for the Member and the donor will be made under this Contract but will be limited by any payment which might be made under any other hospitalization coverage plan. • If the Member is the donor and the recipient is not covered under this Contract, payment for the Member will be made under this Contract limited by any payment which might be made by the recipient’s hospitalization coverage with another company. No payment will be made under this Contract for the recipient. Please see the Limitations and Exclusions section for Non-Covered Services. Covered Services rendered at Urgent Care Centers are covered as outlined in the Summary of Benefits and Coverage. Urgent Care means any medical care or treatment of a medical condition that (A) could seriously jeopardize your Your life or health or your Your ability to regain maximum function or (B) in the opinion of the attending Provider, would subject you to severe pain that cannot be adequately managed without care or treatment. Treatment of an Urgent Care medical problem is not life threatening and does not require use of an emergency room at a Hospital; and is not considered an emergency. This Plan plan uses a Pharmacy Benefits Manager (PBM) for the administration of out-patient prescription drug benefits. Magellan Rx Management is the PBM for Alliant Health Plans. For the most up-to-date information about your Your Prescription Benefit Program, call Magellan Rx Customer Service at (000) 000-0000. The Magellan Rx pharmacy network includes local and retail pharmacies throughout the United States. Members may obtain prescription drug Prescription Drug and pharmacy assistance by calling Magellan Rx Customer Service at (000) 000-0000. The Plan plan will provide coverage for drugs, supplies, supplements and administration of a drug (if such services would not otherwise be excluded from coverage) when prescribed by a licensed and qualified Provider and obtained at a participating pharmacy. The Plan plan uses a Drug Formularydrug formulary, which is a list of Prescription Drugs that are covered by the Planplan. The Drug Formulary drug formulary includes brand-name and generic medications that have undergone a careful review by a committee of practicing physicians and pharmacists. This committee reviews new and existing medications for safety and efficacy, and decides which medications provide quality treatment at the best value. While the Drug Formulary drug formulary is intended to provide comprehensive coverage of your Your prescription medication needs, there are some products that are not covered or have limited availability. For medications that are not on the formulary or are not covered by your Your prescription benefit program, talk to your Your physician about alternative medications. If you You have questions regarding the Drug Formulary drug formulary or regarding your Your Prescription Drug Planplan, call Magellan Rx Customer Service at (000) 000-0000 or visit our Our website at XxxxxxxXxxxx.xxx to view the Drug Formularydrug formulary. Additional information regarding Prescription Drug limitations and exclusions can be found in the Exclusions section of this Certificate. Your benefit design as shown in the Summary of Benefits and Coverage will determine the Copayment copayment or Coinsurance of your Your Prescription Drug program for preferred formulary drugs and non-preferred drugs that are listed on the Drug Formularydrug formulary. For prescription drugs and diabetic supplies rendered by a pharmacy, the MAC is the amount determined by us Us using Prescription Drug cost information provided by the PBM. Where copayments exist, the copayment is expressed as a single fill or for a 31- day supply, whichever is less. Where multiple month fills (90-days for example) are made available, copayment would be required for each month (3 copayments for a 90-day fill). At the time the prescription is dispensed; present your Your Identification Card at the inIn-network Network pharmacy. The In-Network pharmacy will complete and submit the claim for youYou. If you You do not go to an In-Network pharmacy, you You will need to submit the itemized xxxx to be processed.

Prior Authorization Requirement. All transplant procedures must be Prior Authorized for type of transplant and be Medically Necessary and not Experimental or Investigational according to criteria established by Alliant. To Prior Authorize, call (000) 000-0000. The Prior Authorization requirements are a part of the benefit administration of the Contract and are not a treatment recommendation. The actual course of medical treatment the Member chooses remains strictly a matter between the Member and his or her Physician. Your Physician must submit a complete medical history, including current diagnosis and name of the surgeon who will perform the transplant. The surgery must be performed at an Alliant-approved Transplant Centertransplant center. The donor, donor recipient, and the transplant surgery must meet required medical selection criteria as defined by Alliant. If the transplant involves a living donor, benefits are as follows: • If a Member receives a transplant and the donor is also covered under this Contract, payment for the Member and the donor will be made under each Member’s Coverage. • If the donor is not covered under this Contract, payment for the Member and the donor will be made under this Contract but will be limited by any payment which might be made under any other hospitalization coverage plan. • If the Member is the donor and the recipient is not covered under this Contract, payment for the Member will be made under this Contract limited by any payment which might be made by the recipient’s hospitalization coverage with another company. No payment will be made under this Contract for the recipient. Please see the Limitations and Exclusions section for Non-Covered Services. Covered Services rendered at Urgent Care Centers are covered paid as outlined in the Summary of Benefits and Coverage. Urgent Care means any medical care or treatment of a medical condition that (A) could seriously jeopardize your life or health or your ability to regain maximum function or (B) in the opinion of the attending Provider, would subject you to severe pain that cannot be adequately managed without care or treatment. Treatment of an Urgent Care medical problem is not life threatening and does not require use of an emergency room at a Hospital; and is not considered an emergency. (Be aware that large group plans are not required to offer out-patient Prescription Drug benefits; verify coverage with your Human Resources Department if you are a member of a large group account.) This Plan uses a Pharmacy Benefits Manager (PBM) for the administration of out-patient prescription drug benefits. Magellan Rx Management is the PBM for Alliant Health Plans. For the most up-to-date information about your Prescription Benefit Programprescription benefit program, call Magellan Rx Customer Service customer service at (000) 000-0000. The Magellan Rx pharmacy network includes local and retail pharmacies throughout the United States. Members may obtain prescription drug and pharmacy assistance by calling the Magellan Rx Customer Service customer service at (000) 000-0000. The Plan plan will provide coverage for drugs, supplies, supplements and administration of a drug (if such services would not otherwise be excluded from coverage) when prescribed by a licensed and qualified Provider and obtained at a participating pharmacy. The Plan plan uses a Drug Formularydrug formulary, which is a list of Prescription Drugs that are covered by the Planplan. The Drug Formulary drug formulary includes brand-name and generic medications that have undergone a careful review by a committee of practicing physicians and pharmacists. This committee reviews new and existing medications for safety and efficacy, and decides which medications provide quality treatment at the best value. While the Drug Formulary drug formulary is intended to provide comprehensive coverage of your prescription medication needs, there are some products that are not covered or have limited availability. For medications that are not on the formulary or are not covered by your prescription benefit program, talk to your physician about alternative medications. If you have questions regarding the Drug Formulary drug formulary or regarding your Prescription Drug Planprescription drug plan, call Magellan Rx Customer Service at (000) 000-0000 or visit our website at XxxxxxxXxxxx.xxx to view the Drug Formularydrug formulary. Additional information regarding Prescription Drug limitations and exclusions can be found in the Exclusions exclusions section of this Certificate. Your benefit design as shown in the Summary of Benefits and Coverage will determine the Copayment or Coinsurance of your Prescription Drug program for preferred formulary drugs and non-preferred drugs that are listed on the Drug Formulary. For prescription drugs and diabetic supplies rendered by a pharmacy, the MAC is the amount determined by us using Prescription Drug cost information provided by the PBM. Where copayments exist, the copayment is expressed as a single fill or for a 31- day supply, whichever is less. Where multiple month fills (90-days for example) are made available, copayment would be required for each month (3 copayments for a 90-day fill). At the time the prescription is dispensed; present your Identification Card at the in-network pharmacy. The Inin-Network network pharmacy will complete and submit the claim for you. If you do not go to an Inin-Network network pharmacy, you will need to submit the itemized xxxx bill to be processed.

Prior Authorization Requirement. All transplant procedures must be Prior Authorized for type of transplant and be Medically Necessary and not Experimental or Investigational according to criteria established by Alliant. To Prior Authorize, call (000) 000-0000. The Prior Authorization requirements are a part of the benefit administration of the Contract and are not a treatment recommendation. The actual course of medical treatment the Member chooses remains strictly a matter between the Member and his or her Physician. Your Physician must submit a complete medical history, including current diagnosis and name of the surgeon who will perform the transplant. The surgery must be performed at an Alliant-approved Transplant Centertransplant center. The donor, donor recipient, and the transplant surgery must meet required medical selection criteria as defined by Alliant. If the transplant involves a living donor, benefits are as follows: • If a Member receives a transplant and the donor is also covered under this Contract, payment for the Member and the donor will be made under each Member’s Coverage. • If the donor is not covered under this Contract, payment for the Member and the donor will be made under this Contract but will be limited by any payment which might be made under any other hospitalization coverage plan. • If the Member is the donor and the recipient is not covered under this Contract, payment for the Member will be made under this Contract limited by any payment which might be made by the recipient’s hospitalization coverage with another company. No payment will be made under this Contract for the recipient. Please see the Limitations and Exclusions section for Non-Covered Services. Covered Services rendered at Urgent Care Centers are covered paid as outlined in the Summary of Benefits and Coverage. Urgent Care means any medical care or treatment of a medical condition that (A) could seriously jeopardize your life or health or your ability to regain maximum function or (B) in the opinion of the attending Provider, would subject you to severe pain that cannot be adequately managed without care or treatment. Treatment of an Urgent Care medical problem is not life threatening and does not require use of an emergency room at a Hospital; and is not considered an emergency. (Be aware that large group plans are not required to offer out-patient Prescription Drug benefits; verify coverage with your Human Resources Department if you are a member of a large group account.) This Plan uses a Pharmacy Benefits Manager (PBM) for the administration of out-patient prescription drug benefits. Magellan Rx Management is the PBM for Alliant Health Plans. For the most up-to-date information about your Prescription Benefit Programprescription benefit program, call Magellan Rx Customer Service at (000) 000-0000. The Magellan Rx pharmacy network includes local and retail pharmacies throughout the United States. Members may obtain prescription drug and pharmacy assistance by calling the Magellan Rx Customer Service at (000) 000-0000. The Plan plan will provide coverage for drugs, supplies, supplements and administration of a drug (if such services would not otherwise be excluded from coverage) when prescribed by a licensed and qualified Provider and obtained at a participating pharmacy. The Plan plan uses a Drug Formularydrug formulary, which is a list of Prescription Drugs that are covered by the Planplan. The Drug Formulary drug formulary includes brand-name and generic medications that have undergone a careful review by a committee of practicing physicians and pharmacists. This committee reviews new and existing medications for safety and efficacy, and decides which medications provide quality treatment at the best value. While the Drug Formulary drug formulary is intended to provide comprehensive coverage of your prescription medication needs, there are some products that are not covered or have limited availability. For medications that are not on the formulary or are not covered by your prescription benefit program, talk to your physician about alternative medications. If you have questions regarding the Drug Formulary drug formulary or regarding your Prescription Drug Planprescription drug plan, call Magellan Rx Customer Service at (000) 000-0000 or visit our website at XxxxxxxXxxxx.xxx to view the Drug Formularydrug formulary. Additional information regarding Prescription Drug limitations and exclusions can be found in the Exclusions exclusions section of this Certificate. Your benefit design as shown in the Summary of Benefits and Coverage will determine the Copayment or Coinsurance of your Prescription Drug program for preferred formulary drugs and non-preferred drugs that are listed on the Drug Formulary. For prescription drugs and diabetic supplies rendered by a pharmacy, the MAC is the amount determined by us using Prescription Drug cost information provided by the PBM. Where copayments exist, the copayment is expressed as a single fill or for a 31- day supply, whichever is less. Where multiple month fills (90-days for example) are made available, copayment would be required for each month (3 copayments for a 90-day fill). At the time the prescription is dispensed; present your Identification Card at the in-network pharmacy. The Inin-Network network pharmacy will complete and submit the claim for you. If you do not go to an Inin-Network network pharmacy, you will need to submit the itemized xxxx bill to be processed.

Prior Authorization Requirement. All transplant procedures must be Prior Authorized for type of transplant and be Medically Necessary and not Experimental or Investigational according to criteria established by Alliant. To Prior Authorize, call (000) 000-0000. The Prior Authorization requirements are a part of the benefit administration of the Contract and are not a treatment recommendation. The actual course of medical treatment the Member chooses remains strictly a matter between the Member and his or her Physician. Your Physician must submit a complete medical history, including current diagnosis and name of the surgeon who will perform the performthe transplant. The surgery must be performed at an Alliant-approved Transplant Center. The donor, donor recipient, and the transplant surgery must meet required medical selection criteria as defined by Alliant. If the transplant involves a living donor, benefits are as follows: • If a Member receives a transplant and the donor is also covered under this Contract, payment for the Member and the donor will be made under each Member’s Coverage. • If the donor is not covered under this Contract, payment for the Member and the donor will be made under this Contract but will be limited by any payment which might be made under any other hospitalization coverage plan. • If the Member is the donor and the recipient is not covered under this Contract, payment for the Member will be made under this Contract limited by any payment which might be made by the recipient’s hospitalization coverage with coveragewith another company. No payment will be made under this Contract for the recipient. Please see the Limitations and Exclusions section for Non-Covered Services. Covered Services rendered at Urgent Care Centers are covered as outlined in the Summary of Benefits and Coverage. Urgent Care means any medical care or treatment of a medical condition that (A) could seriously jeopardize your Your life or health or your Your ability to regain maximum function or (B) in the opinion of the attending Provider, would subject you You to severe pain that cannot be cannotbe adequately managed without care or treatment. Treatment of an Urgent Care medical problem is not life threatening and does not require use of an emergency room at a Hospital; and is not considered an emergency. This Plan plan uses a Pharmacy Benefits Manager (PBM) for the administration of out-patient prescription drug benefits. Magellan Rx Management RxManagement is the PBM for Alliant Health Plans. For the most up-to-date information about your Your Prescription Benefit Program, call Magellan Rx Customer Service at (000) 000-0000. The Magellan Rx pharmacy network includes local and retail pharmacies throughout the United States. Members may obtain prescription drug obtainPrescription Drug and pharmacy assistance by calling Magellan Rx Customer Service at (000) 000-0000. The Plan plan will provide coverage for drugs, supplies, supplements and administration of a drug (if such services would not otherwise be excluded from coverage) when prescribed by a licensed and qualified Provider and obtained at a participating pharmacy. The Plan plan uses a Drug Formularydrug formulary, which is a list of Prescription Drugs that are covered by the Planplan. The Drug Formulary drug formulary includes brand-name and generic medications that have undergone a careful review by a committee of practicing physicians and pharmacistsandpharmacists. This committee reviews new and existing medications for safety and efficacy, and decides which medications provide quality treatment at the best value. While the Drug Formulary drug formulary is intended to provide comprehensive coverage of your Your prescription medication needs, there are some products that are not covered or have limited availability. For medications that are not on the formulary or are not covered by your Your prescription benefit program, talk to your Your physician about alternative medications. If you You have questions regarding the Drug Formulary drug formulary or regarding your Your Prescription Drug Planplan, call Magellan Rx Customer Service at (000) 000-0000 or visit our Our website at XxxxxxxXxxxx.xxx to view the Drug Formularydrug formulary. Additional information regarding Prescription Drug limitations and exclusions can be found in the Exclusions section of this Certificate. Your benefit design as shown in the Summary of Benefits and Coverage will determine the Copayment copayment or Coinsurance of your Prescription YourPrescription Drug program for preferred formulary drugs and non-preferred drugs that are listed on the Drug Formularydrug formulary. For prescription drugs and diabetic supplies rendered by a pharmacy, the MAC is the amount determined by us Us using Prescription Drug PrescriptionDrug cost information provided by the PBM. Where copayments exist, the copayment is expressed as a single fill or for a 31- day supply, whichever is less. Where multiple month fills (90-days for example) are made available, copayment would be required for each month (3 copayments for a 90-day fill). At the time the prescription is dispensed; present your Your Identification Card at the inIn-network Network pharmacy. The In-Network pharmacy will complete and submit the claim for youYou. If you You do not go to an In-Network pharmacy, you You will need to submit the itemized xxxx theitemized bill to be processed.

Prior Authorization Requirement. All transplant procedures must be Prior Authorized for type of transplant and be Medically Necessary and not Experimental or Investigational according to criteria established by Alliant. To Prior Authorize, call (000) 000-0000. The Prior Authorization requirements are a part of the benefit administration of the Contract and are not a treatment recommendation. The actual course of medical treatment the Member chooses remains strictly a matter between the Member and his or her Physician. Your Physician must submit a complete medical history, including current diagnosis and name of the surgeon who will perform the transplant. The surgery must be performed at an Alliant-approved Transplant Center. The donor, donor recipient, and the transplant surgery must meet required medical selection criteria as defined by Alliant. If the transplant involves a living donor, benefits are as follows: • If a Member receives a transplant and the donor is also covered under this Contract, payment for the Member and the donor will be made under each Member’s Coverage. • If the donor is not covered under this Contract, payment for the Member and the donor will be made under this Contract but will be limited by any payment which might be made under any other hospitalization coverage plan. • If the Member is the donor and the recipient is not covered under this Contract, payment for the Member will be made under this Contract limited by any payment which might be made by the recipient’s hospitalization coverage with another company. No payment will be made under this Contract for the recipient. Please see the Limitations and Exclusions section for Non-Covered Services. URGENT CARE SERVICES‌ Covered Services rendered at Urgent Care Centers are covered as outlined in the Summary of Benefits and Coverage. Urgent Care means any medical care or treatment of a medical condition that (A) could seriously jeopardize your life or health or your ability to regain maximum function or (B) in the opinion of the attending Provider, would subject you to severe pain that cannot be adequately managed without care or treatment. Treatment of an Urgent Care medical problem is not life threatening and does not require use of an emergency room at a Hospital; and is not considered an emergency. OUTPATIENT PRESCRIPTION DRUG PROGRAM‌ This Plan uses a Pharmacy Benefits Manager (PBM) for the administration of out-patient prescription drug benefits. Magellan Rx Management is the PBM for Alliant Health Plans. For the most up-to-date information about your Prescription Benefit Program, call Magellan Rx Customer Service at (000) 000-0000. The Magellan Rx pharmacy network includes local and retail pharmacies throughout the United States. Members may obtain prescription drug and pharmacy assistance by calling the Magellan Rx Customer Service Care at (000) 000-0000. The Plan will provide coverage for drugs, supplies, supplements and administration of a drug (if such services would not otherwise be excluded from coverage) when prescribed by a licensed and qualified Provider and obtained at a participating pharmacy. The Plan uses a Drug Formulary, which is a list of Prescription Drugs that are covered by the Plan. The Drug Formulary includes brand-name and generic medications that have undergone a careful review by a committee of practicing physicians and pharmacists. This committee reviews new and existing medications for safety and efficacy, and decides which medications provide quality treatment at the best value. While the Drug Formulary is intended to provide a comprehensive coverage of your prescription medication needs, there are some products that are not covered or have limited availability. For medications that are not on the formulary or are not covered by your prescription benefit program, talk to your physician about alternative medications. If you have questions regarding the Drug Formulary or regarding your Prescription Drug Plan, call Magellan Rx Customer Service at (000) 000-0000 or visit our website at XxxxxxxXxxxx.xxx to view the Drug Formulary. Additional information regarding Prescription Drug limitations and exclusions can be found in the Exclusions section of this Certificate. Your benefit design as shown in the Summary of Benefits and Coverage will determine the Copayment or Coinsurance of your Prescription Drug program for preferred formulary drugs and non-preferred drugs that are listed on the Drug Formulary. For prescription drugs and diabetic supplies rendered by a pharmacy, the MAC is the amount determined by us using Prescription Drug prescription drug cost information provided by the PBM. At the time the prescription is dispensed; present your Identification Card at the in-network pharmacy. The Inin-Network network pharmacy will complete and submit the claim for you. If you do not go to an Inin-Network network pharmacy, you will need to submit the itemized xxxx to be processed. BENEFITS‌ The Prescription Drug Program provides coverage for drugs which, under federal law, may only be dispensed with a prescription written by a Physician. This program allows for refills of a prescription within one year of the original prescription date, as authorized by your Physician. A limited number of Prescription Drugs require Prior Authorization for Medical Necessity. Prior authorization is a requirement that your physician obtain approval to prescribe a specific medication for you. We review requests for these selected drugs to help ensure appropriate and safe use of medications for your medical condition(s). If Prior Authorization is not approved, then the designated drug will not be eligible for coverage. For a List of select medications that require prior authorization, please contact Magellan Rx Customer Service at (000) 000-0000. Covered Services May Include:‌ Retail prescription medications that have been prescribed by a Provider. Retail Prescription Drugs shall, in all cases, be dispensed per the Drug Formulary for prescriptions written and filled in-n etwork and out-of- network. Only those Prescription Drugs included in the Drug Formulary, as amended from time to time by Alliant, may be Covered Services, except as noted below or otherwise provided in the Drug Formulary. Specialty Drugs‌ Specialty Drugs are typically high-cost, injectable, infused, oral or inhaled medications that generally require close supervision and monitoring of their effect on the patient by a medical professional. Specialty Drugs often require special handling such as temperature controlled packaging and overnight delivery and are often unavailable at retail pharmacies. Most Specialty Drugs require Prior Authorization. You may obtain the list of Specialty Drugs and contracted Specialty Pharmacies by contacting Magellan Rx Customer Care at (000) 000-0000 or online at XxxxxxxXxxxx.xxx. You or your Physician may order your Specialty Drugs from a number of Specialty Pharmacies. The first time a Specialty Drug is ordered for home use, a representative will contact you to gather important information to schedule your first delivery from Magellan Rx Pharmacy. To obtain a Specialty Drug for home use, you must have a prescription for the drug which is signed by a Physician and which states the drug name, dosage, directions for use, quantity, the Physician’s name and phone number, and the patient’s name and address. If the Specialty Drug is ordered via telephone, any Copayment or Coinsurance due can be paid by credit card or debit card. When submitting a paper prescription, a completed order form is required along with your Coinsurance or Copayment payable by check, money order, and credit or debit card. Specialty Pharmacies will deliver your Specialty Drug prescriptions via common overnight carrier and are shipped directly to you or, if necessary, to a Provider for administration. Your treatment plan and specific prescription will determine where administration of the drug will occur and by whom. Additionally, your Copayment and/or Coinsurance may be prorated to support the method of distribution and treatment. If a Provider charges an administration fee for Specialty Drugs, that amount would be separate from the cost of the medication. Charges for drug administration are considered medical services which are subject to the Copayment, Coinsurance and percentage payable provisions as explained in the Summary of Benefits and Coverage. Alliant Health Plans partners with Magellan Rx Management because we are all dedicated to providing quality service and personalized care. Together, we make it easy for you to quickly get your specialty medications while providing additional support to help you stay on track. We will stay in touch over the course of your therapy and will call with monthly refill reminders and address any questions you may have about your treatment. In addition, you also have access to many helpful services: • Insurance specialists to help you get the most out of your benefits • Clinical programs to help manage your condition • Educational materials about your condition or medication, including at-home guides • Free delivery to your home or another address within two days of ordering • Important supplies at no additional cost, such as syringes and needles • Highly trained pharmacists and nurses available toll-free to answer any questions • Online member portal where you can request refills and learn more TIER ASSIGNMENT PROCESS‌ We have either established or delegate responsibility to a Pharmacy and Therapeutics (P&T) Committee, consisting of health care professionals, including nurses, pharmacists, and physicians. The purpose of this committee is to assist in determining clinical appropriateness of drugs, determining the tier assignments of drugs, and advising on programs to help improve care. Such programs may include, but are not limited to, drug utilization programs, Prior Authorization criteria, therapeutic conversion programs, cross-branded initiatives, step-therapy protocols, drug profiling initiatives and the like. Some of these programs will require additional information from your doctor in order to meet requirements. For more information about these programs and how Alliant Health Plans administers them, please call Customer Service at (000) 000-0000. The determination of tiers is made by Alliant based upon clinical decisions provided by the P&T Committee, and where appropriate, the cost of the drug relative to other Drugs in its therapeutic class or used to treat the same or similar condition; the availability of over-the-counter alternative; and where appropriate, certain clinical economic factors. We retain the right at our discretion to determine coverage for dosage formulations in terms of covered dosage administration methods (for example, by oral, injectable, topical, or inhaled) and may cover one form of administration and exclusion or place other forms of administration in another tier. Drug Tiers‌ The amount you will pay for a Prescription Drug depends on the t ier of the drug you receive. Refer to your Summary of Benefit and Coverage to determine your Copayment, Coinsurance and Deductible (if any) amounts. Prescription Drugs will always be dispensed as ordered by your Physician. You may request, or your Physician may order, the Brand Name Drug. However, if a Generic Drug is available, you will be responsible for the difference in the allowable charge between the Generic and Brand Name Drug, in addition to your generic Copayment. The difference you will be charged between the two drug costs does not include the Copayment, if applicable. The difference you will be charged between the two drug costs does not include the Copayment, if applicable. This difference is referred to as a DAW (Dispense as Written) Penalty.

Prior Authorization Requirement. All transplant procedures must be Prior Authorized for type of transplant and be Medically Necessary and not Experimental or Investigational according to criteria established by Alliant. To Prior Authorize, call (000) 000-0000. The Prior Authorization requirements are a part of the benefit administration of the Contract and are not a treatment recommendation. The actual course of medical treatment the Member chooses remains strictly a matter between the Member and his or her Physician. Your Physician must submit a complete medical history, including current diagnosis and name of the surgeon who will perform the transplant. The surgery must be performed at an Alliant-approved Transplant Center. The donor, donor recipient, and the transplant surgery must meet required medical selection criteria as defined by Alliant. If the transplant involves a living donor, benefits are as follows: • If a Member receives a transplant and the donor is also covered under this Contract, payment for the Member and the donor will be made under each Member’s Coverage. • If the donor is not covered under this Contract, payment for the Member and the donor will be made under this Contract but will be limited by any payment which might be made under any other hospitalization coverage plan. • If the Member is the donor and the recipient is not covered under this Contract, payment for the Member will be made under this Contract limited by any payment which might be made by the recipient’s hospitalization coverage with another company. No payment will be made under this Contract for the recipient. Please see the Limitations and Exclusions section for Non-Covered Services. Covered Services rendered at Urgent Care Centers are covered as outlined in the Summary of Benefits and Coverage. Urgent Care means any medical care or treatment of a medical condition that (A) could seriously jeopardize your life or health or your ability to regain maximum function or (B) in the opinion of the attending Provider, would subject you to severe pain that cannot be adequately managed without care or treatment. Treatment of an Urgent Care medical problem is not life threatening and does not require use of an emergency room at a Hospital; and is not considered an emergency. This Plan plan uses a Pharmacy Benefits Manager (PBM) for the administration of out-patient prescription drug benefits. Magellan Rx Management is the PBM for Alliant Health Plans. For the most up-to-date information about your Prescription Benefit Program, call Magellan Rx Customer Service at (000) 000-0000. The Magellan Rx pharmacy network includes local and retail pharmacies throughout the United States. Members may obtain prescription drug Prescription Drug and pharmacy assistance by calling Magellan Rx Customer Service at (000) 000-0000. The Plan plan will provide coverage for drugs, supplies, supplements and administration of a drug (if such services would not otherwise be excluded from coverage) when prescribed by a licensed and qualified Provider and obtained at a participating pharmacy. The Plan plan uses a Drug Formularydrug formulary, which is a list of Prescription Drugs that are covered by the Planplan. The Drug Formulary drug formulary includes brand-name and generic medications that have undergone a careful review by a committee of practicing physicians and pharmacists. This committee reviews new and existing medications for safety and efficacy, and decides which medications provide quality treatment at the best value. While the Drug Formulary drug formulary is intended to provide comprehensive coverage of your prescription medication needs, there are some products that are not covered or have limited availability. For medications that are not on the formulary or are not covered by your prescription benefit program, talk to your physician about alternative medications. If you have questions regarding the Drug Formulary drug formulary or regarding your Prescription Drug Planplan, call Magellan Rx Customer Service customer service at (000) 000-0000 or visit our website at XxxxxxxXxxxx.xxx to view the Drug Formularydrug formulary. Additional information regarding Prescription Drug limitations and exclusions can be found in the Exclusions section of this Certificate. Your benefit design as shown in the Summary of Benefits and Coverage will determine the Copayment copayment or Coinsurance of your Prescription Drug program for preferred formulary drugs and non-preferred drugs that are listed on the Drug Formularydrug formulary. For prescription drugs and diabetic supplies rendered by a pharmacy, the MAC is the amount determined by us using Prescription Drug cost information provided by the PBM. Where copayments exist, the copayment is expressed as a single fill or for a 31- day supply, whichever is less. Where multiple month fills (90-days for example) are made available, copayment would be required for each month (3 copayments for a 90-day fill). At the time the prescription is dispensed; present your Identification Card at the inIn-network Network pharmacy. The In-Network pharmacy will complete and submit the claim for you. If you do not go to an In-Network pharmacy, you will need to submit the itemized xxxx bill to be processed.