Common use of Scans in an Outpatient Setting Clause in Contracts

Scans in an Outpatient Setting. Positron Emission Tomography (PET) is a noninvasive diagnostic imaging procedure that quantifies biochemical processes in living tissue. Positron Emission Tomography (PET) scans in an outpatient setting require Prior Authorization. This benefit has one or more exclusions as specified in the Exclusions Section. Practitioner/Provider services are those services that are reasonably required to maintain good health. Practitioner/Provider services include, but are not limited to, periodic examinations and office visits by: • A licensed Practitioner/Provider • Specialist services provided by other Health Care Professionals who are licensed to practice, are certified, and practicing as authorized by applicable law or authority • A medical group • An independent practice association • Other authority authorized by applicable state law Some Practitioner/Provider services require Prior Authorization. Refer to the Prior Authorization Section for Prior Authorization requirements. This Benefit includes, but not limited to, consultation and Health Care Services and supplies provided by your Practitioner/Provider as shown below: • Office visits/telemedicine visits provided by a qualified Practitioner/Provider. • Video Visits provided online between a designated Practitioner/Provider and patient about non-urgent healthcare matters. • Outpatient surgery and Inpatient surgery including necessary anesthesia services. Anesthesia may include hypnotherapy. • Hospital and Skilled Nursing Facility visits as part of continued supervision of Covered care‌‌ • Allergy Services, including testing and serum • Sterilization procedures • Student Health Centers: Dependent Students attending school either in New Mexico or outside New Mexico may receive care through their Primary Care Physician or at the Student Health Center. A Prior Authorization is not needed prior to receiving care from the Student Health Center. Services provided outside of the Student Health Center are limited to Medically Necessary Covered services for the initial care or treatment of an Emergency Health Care Service or Urgent Care situation. • Second medical opinions. Cost Sharing will apply when you or your Practitioner/Provider requests the second medical opinion. Cost Sharing will not apply if we require a second medical opinion to evaluate the medical appropriateness of a diagnosis or service. This benefit has one or more exclusions as specified in the Exclusions Section.

Scans in an Outpatient Setting. Positron Emission Tomography (PET) is a noninvasive diagnostic imaging procedure that quantifies biochemical processes in living tissue. Positron Emission Tomography (PET) scans in an outpatient setting require Prior Authorization. This benefit has one or more exclusions as specified in the Exclusions Section. Practitioner/Provider services are those services that are reasonably required to maintain good health. Practitioner/Provider services include, but are not limited to, periodic examinations and office visits by: • A licensed Practitioner/Provider • Specialist services provided by other Health Care Professionals who are licensed to practice, are certified, and practicing as authorized by applicable law or authority • A medical group • An independent practice association • Other authority authorized by applicable state law Some Practitioner/Provider services require Prior Authorization. Refer to the Prior Authorization Section for Prior Authorization requirements. This Benefit includes, but not limited to, consultation and Health Care Services and supplies provided by your Practitioner/Provider as shown below: • Office visits/telemedicine visits provided by a qualified Practitioner/Provider. • Video Visits provided online between a designated Practitioner/Provider and patient about non-urgent healthcare matters. • Outpatient surgery and Inpatient surgery including necessary anesthesia services. Anesthesia may include hypnotherapy. • Hospital and Skilled Nursing Facility visits as part of continued supervision of Covered care‌‌ care • Allergy Services, including testing and serum • Sterilization procedures • Student Health Centers: Dependent Students attending school either in New Mexico or outside New Mexico may receive care through their Primary Care Physician or at the Student Health Center. A Prior Authorization is not needed prior to receiving care from the Student Health Center. Services provided outside of the Student Health Center are limited to Medically Necessary Covered services for the initial care or treatment of an Emergency Health Care Service or Urgent Care situation. • Second medical opinions. Cost Sharing will apply when you or your Practitioner/Provider requests the second medical opinion. Cost Sharing will not apply if we require a second medical opinion to evaluate the medical appropriateness of a diagnosis or service. This benefit has one or more exclusions as specified in the Exclusions Section.

Scans in an Outpatient Setting. Positron Emission Tomography (PET) is a noninvasive diagnostic imaging procedure that quantifies biochemical processes in living tissue. Positron Emission Tomography (PET) scans in an outpatient setting require Prior Authorization. This benefit has one or more exclusions as specified in the Exclusions Section. Practitioner/Provider services are those services that are reasonably required to maintain good health. Practitioner/Provider services include, but are not limited to, periodic examinations and office visits by: • · A licensed Practitioner/Provider • · Specialist services provided by other Health Care Healthcare Professionals who are licensed to practice, are certified, and practicing as authorized by applicable law or authority • · A medical group • · An independent practice association • · Other authority authorized by applicable state law Some Practitioner/Provider services require Prior Authorization. Refer to the Prior Authorization Section for Prior Authorization requirements. This Benefit includes, but not limited to, consultation and Health Care Healthcare Services and supplies provided by your Practitioner/Provider as shown below: • · Office visits/telemedicine visits provided by a qualified Practitioner/Provider. • · Presbyterian Health Plan (PHP) Video Visits provided online between a designated Practitioner/Provider and patient about non-urgent healthcare matters. • PHP Video Visits utilizes Walmart Health Virtual Care’s nationwide network of Providers. · Telehealth appointments through video or phone are with a network Provider, including Presbyterian Medical Group Providers. · Online visits are an online medical interview followed by a response from a Presbyterian Medical Group Provider. · behavioral health services will be provided via telemedicine on the same terms as physical health services in compliance with the telemedicine parity and mental health parity laws · Outpatient surgery and Inpatient surgery including necessary anesthesia services. Anesthesia may include hypnotherapy. • · Hospital and Skilled Nursing Facility visits as part of continued supervision of Covered care‌‌ • care · Allergy Services, including testing and serum • · Sterilization procedures • · Student Health Centers: Dependent Students attending school either in New Mexico the 5-county area or outside New Mexico the 5-county area may receive care through their Primary Care Physician or at the Student Health Center. A Prior Authorization is not needed prior to receiving care from the Student Health Center. Services provided outside of the Student Health Center are limited to Medically Necessary Covered services for the initial care or treatment of an Emergency Health Care Healthcare Service or Urgent Care situation. • · Second medical opinions. Cost Sharing will apply when you or your Practitioner/Provider requests the second medical opinion. Cost Sharing will not apply if we require a second medical opinion to evaluate the medical appropriateness of a diagnosis or service. This benefit has one or more exclusions as specified in the Exclusions Section.

Scans in an Outpatient Setting. Positron Emission Tomography (PET) is a noninvasive diagnostic imaging procedure that quantifies biochemical processes in living tissue. Positron Emission Tomography (PET) scans in an outpatient setting require Prior Authorization. This benefit has one or more exclusions as specified in the Exclusions Section. Practitioner/Provider services are those services that are reasonably required to maintain good health. Practitioner/Provider services include, but are not limited to, periodic examinations and office visits by: • A licensed Practitioner/Provider • Specialist services provided by other Health Care Healthcare Professionals who are licensed to practice, are certified, and practicing as authorized by applicable law or authority • A medical group • An independent practice association • Other authority authorized by applicable state law Some Practitioner/Provider services require Prior Authorization. Refer to the Prior Authorization Section for Prior Authorization requirements. This Benefit includes, but not limited to, consultation and Health Care Healthcare Services and supplies provided by your Practitioner/Provider as shown below: • Office visits/telemedicine visits provided by a qualified Practitioner/Provider. • PHP Video Visits provided online between a designated Practitioner/Provider and patient about non-urgent healthcare matters. PHP Video Visits utilize MeMD’s nationwide network of Providers and are $0 for all members that are not on a qualified high- deductible plan. • Telehealth appointments through video or telephone are with a network Provider, including Presbyterian Medical Group Providers. • Online Visits are an online medical interview followed by a response from a Presbyterian Medical Group Provider. They are $0 for all members that are not on a qualified high- deductible plan. • Outpatient surgery and Inpatient surgery including necessary anesthesia services. Anesthesia may include hypnotherapyHypnotherapy is Covered as part of anesthesia preparation. • Hospital and Skilled Nursing Facility visits as part of continued supervision of Covered care‌‌ care • Allergy Services, including testing and serum • Sterilization procedures • Student Health Centers: Dependent Students attending school either in New Mexico or outside New Mexico may receive care through their Primary Care Physician or at the Student Health Center. A Prior Authorization is not needed prior to receiving care from the Student Health Center. Services provided outside of the Student Health Center are limited to Medically Necessary Covered services for the initial care or treatment of an Emergency Health Care Service or Urgent Care situation. • Second medical opinions. Cost Sharing will apply when you or your Practitioner/Provider requests the second medical opinion. Cost Sharing will not apply if we require a second medical opinion to evaluate the medical appropriateness of a diagnosis or service. This benefit has one or more exclusions as specified in the Exclusions Section.

Scans in an Outpatient Setting. Positron Emission Tomography (PET) is a noninvasive diagnostic imaging procedure that quantifies biochemical processes in living tissue. Positron Emission Tomography (PET) scans in an outpatient setting require Prior Authorization. This benefit has one or more exclusions as specified in the Exclusions Section. Practitioner/Provider services are those services that are reasonably required to maintain good health. Practitioner/Provider services include, but are not limited to, periodic examinations and office visits by: • A licensed Practitioner/Provider • Specialist services provided by other Health Care Healthcare Professionals who are licensed to practice, are certified, and practicing as authorized by applicable law or authority • A medical group • An independent practice association • Other authority authorized by applicable state law law‌‌ Some Practitioner/Provider services require Prior Authorization. Refer to the Prior Authorization Section for Prior Authorization requirements. This Benefit includes, but not limited to, consultation and Health Care Healthcare Services and supplies provided by your Practitioner/Provider as shown below: • Office visits/telemedicine visits provided by a qualified Practitioner/Provider. • PHP Video Visits provided online between a designated Practitioner/Provider and patient about non-urgent healthcare matters. • PHP Video Visits utilize MeMD’s nationwide network of Providers. • Telehealth appointments through video or phone are with a network Provider, including Presbyterian Medical Group Providers. • Online Visits are an online medical interview followed by a response from a Presbyterian Medical Group Provider. • Outpatient surgery and Inpatient surgery including necessary anesthesia services. Anesthesia may include hypnotherapyHypnotherapy is Covered as part of anesthesia preparation. • Hospital and Skilled Nursing Facility visits as part of continued supervision of Covered care‌‌ care • Allergy Services, including testing and serum • Sterilization procedures • Student Health Centers: Dependent Students attending school either in New Mexico or outside New Mexico may receive care through their Primary Care Physician or at the Student Health Center. A Prior Authorization is not needed prior to receiving care from the Student Health Center. Services provided outside of the Student Health Center are limited to Medically Necessary Covered services for the initial care or treatment of an Emergency Health Care Service or Urgent Care situation. • Second medical opinions. Cost Sharing will apply when you or your Practitioner/Provider requests the second medical opinion. Cost Sharing will not apply if we require a second medical opinion to evaluate the medical appropriateness of a diagnosis or service. This benefit has one or more exclusions as specified in the Exclusions Section.

Scans in an Outpatient Setting. Positron Emission Tomography (PET) is a noninvasive diagnostic imaging procedure that quantifies biochemical processes in living tissue. Positron Emission Tomography (PET) scans in an outpatient setting require Prior Authorization. This benefit has one or more exclusions as specified in the Exclusions Section. Practitioner/Provider services are those services that are reasonably required to maintain good health. Practitioner/Provider services include, but are not limited to, periodic examinations and office visits by: • A licensed Practitioner/Provider • Specialist services provided by other Health Care Professionals who are licensed to practice, are certified, and practicing as authorized by applicable law or authority • A medical group • An independent practice association • Other authority authorized by applicable state law Some Practitioner/Provider services require Prior Authorization. Refer to the Prior Authorization Section for Prior Authorization requirements. This Benefit includes, but not limited to, consultation and Health Care Services and supplies provided by your Practitioner/Provider as shown below: below:‌‌ • Office visits/telemedicine visits provided by a qualified Practitioner/Provider. • Video Visits provided online between a designated Practitioner/Provider and patient about non-urgent healthcare matters. • Outpatient surgery and Inpatient surgery including necessary anesthesia services. Anesthesia may include hypnotherapyHypnotherapy is Covered as part of anesthesia preparation. • Hospital and Skilled Nursing Facility visits as part of continued supervision of Covered care‌‌ care • Allergy Services, including testing and serum • Sterilization procedures • Student Health Centers: Dependent Students attending school either in New Mexico or outside New Mexico may receive care through their Primary Care Physician or at the Student Health Center. A Prior Authorization is not needed prior to receiving care from the Student Health Center. Services provided outside of the Student Health Center are limited to Medically Necessary Covered services for the initial care or treatment of an Emergency Health Care Service or Urgent Care situation. • Second medical opinions. Cost Sharing will apply when you or your Practitioner/Provider requests the second medical opinion. Cost Sharing will not apply if we require a second medical opinion to evaluate the medical appropriateness of a diagnosis or service. This benefit has one or more exclusions as specified in the Exclusions Section.

Scans in an Outpatient Setting. Positron Emission Tomography (PET) is a noninvasive diagnostic imaging procedure that quantifies biochemical processes in living tissue. Positron Emission Tomography (PET) scans in an outpatient setting require Prior Authorization. This benefit has one or more exclusions as specified in the Exclusions Section. Practitioner/Provider services are those services that are reasonably required to maintain good health. Practitioner/Provider services include, but are not limited to, periodic examinations and office visits by: • A licensed Practitioner/Provider • Specialist services provided by other Health Care Healthcare Professionals who are licensed to practice, are certified, and practicing as authorized by applicable law or authority • A medical group • An independent practice association • Other authority authorized by applicable state law Some Practitioner/Provider services require Prior Authorization. Refer to the Prior Authorization Section for Prior Authorization requirements. This Benefit includes, but not limited to, consultation and Health Care Healthcare Services and supplies provided by your Practitioner/Provider as shown below: • Office visits/telemedicine visits provided by a qualified Practitioner/Provider. • Video Visits provided online between a designated Practitioner/Provider and patient about non-urgent healthcare matters. • Outpatient surgery and Inpatient surgery including necessary anesthesia services. Anesthesia may include hypnotherapy. • Hospital and Skilled Nursing Facility visits as part of continued supervision of Covered care‌‌ care • Allergy Services, including testing and serum • Sterilization procedures • Student Health Centers: Dependent Students attending school either in New Mexico the 5-county area or outside New Mexico the 5-county area may receive care through their Primary Care Physician or at the Student Health Center. A Prior Authorization is not needed prior to receiving care from the Student Health Center. Services provided outside of the Student Health Center are limited to Medically Necessary Covered services for the initial care or treatment of an Emergency Health Care Healthcare Service or Urgent Care situation. • Second medical opinions. Cost Sharing will apply when you or your Practitioner/Provider requests the second medical opinion. Cost Sharing will not apply if we require a second medical opinion to evaluate the medical appropriateness of a diagnosis or service. This benefit has one or more exclusions as specified in the Exclusions Section. Outpatient Prescription Drugs are a Covered Benefit when prescribed by your Provider. Refer to your Formulary for information on the approved Prescription Drugs. For a complete list of these drugs, please see the Health Insurance Exchange Metal Level Plan Formulary list at xxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00236101.pdf Insulin or a medically necessary alternative will not exceed a total of twenty-five ($25.00) per thirty-day supply. We will provide Coverage for preventive medications and products as defined by the Affordable Care Act (ACA) if you receive these services from our In-network Practitioners/Providers, without Cost Sharing regardless of sex assigned at birth, gender identity, or gender of the individual. Preventive medications are used for the management and prevention of complications from conditions such as high blood pressure, high cholesterol, diabetes, asthma, osteoporosis, heart attack and stroke. For preventive medications (including over-the-counter medications) or products to be covered, you’ll need to get a prescription from your doctor and a pharmacy claim will need to be submitted. Present your ID card to the dispensing pharmacy for processing and billing information. Visit the formulary listing at xxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00236101.pdf preventive medications will be listed as $0 Copay per PPACA. For a complete list of these preferred products, please see the Presbyterian Pharmacy website at You can contact our Presbyterian Customer Service Center from 7 a.m. to 6 p.m. at (000) 000-0000 or 0-000-000-0000. TTY users may call 711. The following drugs are covered when prescribed by your provider and when purchased at an In- network Pharmacy. Refer to your Formulary for information on the approved Prescription Drugs/Medications. • Medically Necessary prescription nutritional supplements for prenatal care for up to a 90- day supply up to the maximum dosing recommended by the manufacturer. • Preferred insulin and diabetic oral agents for controlling blood sugar levels for up to a 90- day supply up to the maximum dosing recommended by the manufacturer. • Immunosuppressant drugs following transplant surgery for up to a 90-day supply up to the maximum dosing recommended by the manufacturer. • Special Medical Foods used in treatment to compensate and maintain adequate nutritional status for genetic Inborn Errors of Metabolism (IEM). These Special Medical Foods require Prior Authorization. • Smoking Cessation Pharmacotherapy. Formulary drugs for up to a 90-day supply up to the maximum dosing recommended by the manufacturer. Smoking cessation is limited to two 90-day courses of treatment per contract year. A drug formulary, or preferred drug list, is a continually updated list of medications and related products supported by current evidence-based medicine, judgment of physicians, pharmacists and other experts in the diagnosis and treatment of disease and preservation of health. The primary purpose of the formulary is to encourage the use of safe, effective and most affordable medications. Presbyterian Health Plan administers a closed formulary, which means that non-formulary drugs are not routinely reimbursed by the plan. Medical exception policies provide access to non-formulary medication when Medical necessity is established. The medications listed on the formulary are subject to change pursuant to the management activities of Presbyterian Health Plan. For the most up-to-date formulary drug information, visit xxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00236101.pdf. Presbyterian will provide material that contains in a clear, conspicuous and readily understandable form, a full and fair disclosure of the plan’s benefits, limitations, exclusions, conditions of eligibility and prior authorization requirements, within a reasonable time after enrollment and at subsequent periodic times as appropriate. The Formulary can change throughout the year. Some reasons why it can change include: • New drugs are approved • Existing drugs are removed from the market • Prescription drugs may become available over the counter (without a prescription) • Brand-name drugs lose patient protection and generic versions become available. • Changes based on new clinical guidelines If we remove drugs from our Formulary, add quantity limits, prior authorization, and/or step therapy restrictions on a drug; or move a drug to a higher Cost Charing tier, we must notify affected members of the change at least 60 days before the change becomes effective. The medications and related products listed on a formulary are determined by a Pharmacy and Therapeutics (P & T) Committee or an equivalent entity. The Presbyterian Health Plan P & T Committee is made up of primary care and specialty physicians, clinical pharmacists and other professionals in the healthcare field. The P&T Committee meets quarterly to promote the appropriate use of drugs, to maintain the Presbyterian formularies, and to support our network of practitioners. Medications chosen for the formulary are selected based on their safety, effectiveness and overall value. A medication may not be added to the formulary if current drugs on the formulary are equally safe and effective and are less costly. Utilization management strategies such as quantity limits, step therapy and prior authorization criteria are reviewed and approved by the P & T committee. Medication coverage criteria is updated and reviewed to reflect current standards of practice. The overall goal of the P & T Committee is to provide a formulary that gives members access to safe, appropriate, and cost-effective medications that will produce the desired goals of therapy at the most reasonable cost to the member and the healthcare system. Changes to the Presbyterian formulary are made effective at least 45 days after the quarterly meeting. If a change to the formulary negatively impacts utilizing members, the members are granted a 60-day transition period. Members impacted will receive a Formulary Change Notification letter with details about the change, the effective date of the change and formulary alternatives if available. Prior Authorization is a clinical evaluation process to determine if the requested Healthcare Service is Medically Necessary, a Covered Benefit, and if it is being delivered in the most appropriate healthcare setting. Our Medical Director or other clinical professional will review the requested Healthcare Service in consultation with your medical provider, and if it meets our requirements for Coverage and Medical Necessity, it is Authorized (approved) before those services are provided. The Prior Authorization process and requirements are regularly reviewed and updated based on various factors including evidence-based practice guidelines, medical trends, Practitioner/Provider participation, state and federal regulations, and our policies and procedures. • Continuation of therapy using any drug is dependent upon its demonstrable efficacy. • Note that the prior use of free prescription medications (i.e. Samples, free goods, etc.) will not be considered in the evaluation of a member’s eligibility for medication coverage. Step Therapy promotes the appropriate use of equally effective but lower-cost formulary drugs first. With this program, prior use of one or more “prerequisite” drugs is required before a step-therapy medication will be covered. Prerequisite drugs are FDA-approved and treat the same condition as the corresponding step- therapy drugs. Formulary drugs may also limit coverage of quantities for certain drugs. These limits help your doctor and pharmacist check that the medications are used appropriately and promote patient safety. Presbyterian uses medical guidelines and FDA-approved recommendations from drug makers to set these coverage limits. Quantity limits include the following: • Maximum Daily Dose limits quantities to a maximum number of dosage units (i.e. tablets, capsules, milliliters, milligrams, doses, etc.) in a single day. Limits are based on daily dosages shown to be safe and effective, and that are approved by the Food and Drug Administration (FDA). • Quantity Limits over time limits quantities to number of units (i.e. tablets, capsules, milliliters, milligrams, doses, etc.) in a defined period of time.

Scans in an Outpatient Setting. Positron Emission Tomography (PET) is a noninvasive diagnostic imaging procedure that quantifies biochemical processes in living tissue. Positron Emission Tomography (PET) scans in an outpatient setting require Prior Authorization. This benefit has one or more exclusions as specified in the Exclusions Section. Practitioner/Provider services are those services that are reasonably required to maintain good health. Practitioner/Provider services include, but are not limited to, periodic examinations and office visits by: • A licensed Practitioner/Provider • Specialist services provided by other Health Care Professionals who are licensed to practice, are certified, and practicing as authorized by applicable law or authority • A medical group • An independent practice association • Other authority authorized by applicable state law Some Practitioner/Provider services require Prior Authorization. Refer to the Prior Authorization Section for Prior Authorization requirements. This Benefit includes, but not limited to, consultation and Health Care Services and supplies provided by your Practitioner/Provider as shown below: • Office visits/telemedicine visits provided by a qualified Practitioner/Provider. • Video Visits provided online between a designated Practitioner/Provider and patient about non-urgent healthcare matters. • Outpatient surgery and Inpatient surgery including necessary anesthesia services. Anesthesia may include hypnotherapy. • Hospital and Skilled Nursing Facility visits as part of continued supervision of Covered care‌‌ care • Allergy Services, including testing and serum • Sterilization procedures • Student Health Centers: Dependent Students attending school either in New Mexico or outside New Mexico may receive care through their Primary Care Physician or at the Student Health Center. A Prior Authorization is not needed prior to receiving care from the Student Health Center. Services provided outside of the Student Health Center are limited to Medically Necessary Covered services for the initial care or treatment of an Emergency Health Care Service or Urgent Care situation. • Second medical opinions. Cost Sharing will apply when you or your Practitioner/Provider requests the second medical opinion. Cost Sharing will not apply if we require a second medical opinion to evaluate the medical appropriateness of a diagnosis or service. This benefit has one or more exclusions as specified in the Exclusions Section.

Scans in an Outpatient Setting. Positron Emission Tomography (PET) is a noninvasive diagnostic imaging procedure that quantifies biochemical processes in living tissue. Positron Emission Tomography (PET) scans in an outpatient setting require Prior Authorization. This benefit has one or more exclusions as specified in the Exclusions Section. Practitioner/Provider services are those services that are reasonably required to maintain good health. Practitioner/Provider services include, but are not limited to, periodic examinations and office visits by: • A licensed Practitioner/Provider • Specialist services provided by other Health Care Professionals who are licensed to practice, are certified, and practicing as authorized by applicable law or authority • A medical group • An independent practice association • Other authority authorized by applicable state law Some Practitioner/Provider services require Prior Authorization. Refer to the Prior Authorization Section for Prior Authorization requirements. This Benefit includes, but not limited to, consultation and Health Care Services and supplies provided by your Practitioner/Provider as shown below: • Office visits/telemedicine visits provided by a qualified Practitioner/Provider. • Video Visits provided online between a designated Practitioner/Provider and patient about non-urgent healthcare matters. • Outpatient surgery and Inpatient surgery including necessary anesthesia services. Anesthesia may include hypnotherapy. • Hospital and Skilled Nursing Facility visits as part of continued supervision of Covered care‌‌ care • Allergy Services, including testing and serum • Sterilization procedures • Student Health Centers: Dependent Students attending school either in New Mexico the 5-county area or outside New Mexico the 5-county area may receive care through their Primary Care Physician or at the Student Health Center. A Prior Authorization is not needed prior to receiving care from the Student Health Center. Services provided outside of the Student Health Center are limited to Medically Necessary Covered services for the initial care or treatment of an Emergency Health Care Service or Urgent Care situation. • Second medical opinions. Cost Sharing will apply when you or your Practitioner/Provider requests the second medical opinion. Cost Sharing will not apply if we require a second medical opinion to evaluate the medical appropriateness of a diagnosis or service. This benefit has one or more exclusions as specified in the Exclusions Section.

Scans in an Outpatient Setting. Positron Emission Tomography (PET) is a noninvasive diagnostic imaging procedure that quantifies biochemical processes in living tissue. Positron Emission Tomography (PET) scans in an outpatient setting require Prior Authorization. This benefit has one or more exclusions as specified in the Exclusions Section. Practitioner/Provider services are those services that are reasonably required to maintain good health. Practitioner/Provider services include, but are not limited to, periodic examinations and office visits by: • A licensed Practitioner/Provider • Specialist services provided by other Health Care Professionals who are licensed to practice, are certified, and practicing as authorized by applicable law or authority • A medical group • An independent practice association • Other authority authorized by applicable state law Some Practitioner/Provider services require Prior Authorization. Refer to the Prior Authorization Section for Prior Authorization requirements. This Benefit includes, but not limited to, consultation and Health Care Services and supplies provided by your Practitioner/Provider as shown below: below:‌‌ • Office visits/telemedicine visits provided by a qualified Practitioner/Provider. • Video Visits provided online between a designated Practitioner/Provider and patient about non-urgent healthcare matters. • Outpatient surgery and Inpatient surgery including necessary anesthesia services. Anesthesia may include hypnotherapyHypnotherapy is Covered as part of anesthesia preparation. • Hospital and Skilled Nursing Facility visits as part of continued supervision of Covered care‌‌ care • Allergy Services, including testing and serum • Sterilization procedures • Student Health Centers: Dependent Students attending school either in New Mexico or outside New Mexico may receive care through their Primary Care Physician or at the Student Health Center. A Prior Authorization is not needed prior to receiving care from the Student Health Center. Services provided outside of the Student Health Center are limited to Medically Necessary Covered services for the initial care or treatment of an Emergency Health Care Service or Urgent Care situation. • Second medical opinions. Cost Sharing will apply when you or your Practitioner/Provider requests the second medical opinion. Cost Sharing will not apply if we require a second medical opinion to evaluate the medical appropriateness of a diagnosis or service. This benefit has one or more exclusions as specified in the Exclusions Section. Outpatient Prescription Drugs are a Covered Benefit when prescribed by your Provider. Refer to your Formulary for information on the approved Prescription Drugs. For a complete list of these drugs, please see the Health Insurance Exchange Metal Level Plan Formulary list at xxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00236101.pdf. Insulin or a medically necessary alternative will not exceed a total of twenty-five ($25.00) per thirty-day supply. We will provide Coverage for preventive medications and products as defined by the Affordable Care Act (ACA) if you receive these services from our In-network Practitioner/Providers, without Cost Sharing regardless of sex assigned at birth, gender identity, or gender of the individual. Preventive medications are used for the management and prevention of complications from conditions such as high blood pressure, high cholesterol, diabetes, asthma, osteoporosis, heart attack and stroke. For prevention medications (including over-the-counter medications) or products to be covered, you’ll need to get a prescription from your Provider and a pharmacy will need to be submitted. Present your ID card to the dispensing pharmacy for processing and billing information. Visit the Formulary listing at xxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00236101.pdf. Preventive medications will be listed as $0 Copay per PPACA. For a complete list of these preferred products, please see the Presbyterian Pharmacy website at . You can call our Presbyterian Customer Service Center at (000) 000-0000 or 0-000-000-0000, Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. If the following drugs are covered when prescribed by your provider and when purchased at an In-network Pharmacy. Refer to your Formulary for information on the approved Prescription Drugs/Medications. • Medically Necessary prescription nutritional supplements for prenatal care for up to a 90- day supply up to the maximum dosing recommended by the manufacturer. • Preferred insulin and diabetic oral agents for controlling blood sugar levels for up to a 90- day supply up to the maximum dosing recommended by the manufacturer. • Immunosuppressant drugs following transplant surgery for up to a 90-day supply up to the maximum dosing recommended by the manufacturer. • Special Medical Foods used in treatment to compensate and maintain adequate nutritional status for genetic Inborn Errors of Metabolism (IEM). These Special Medical Foods require Prior Authorization. • Smoking Cessation Pharmacotherapy. Formulary drugs for up to a 90-day supply up to the maximum dosing recommended by the manufacturer. Smoking cessation is limited to two 90-day courses of treatment per contract year. A drug Formulary, or preferred drug list, is a continually updated list of medications and related products supported by current evidence-based medicine, judgment of physicians, pharmacists and other experts in the diagnosis and treatment of disease and preservation of health. The primary purpose of the Formulary is to encourage the use of safe, effective and most affordable medications. Presbyterian Insurance Company administers a closed Formulary, which means that non-formulary drugs are not routinely reimbursed by the plan. Medical exception policies provide access to non-formulary medications when Medical Necessity is established. The medications listed on the Formulary are subject to change pursuant to the management activities of Presbyterian Insurance Company. For the most up-to-date Formulary drug information, visit xxxx://xxxx.xxx.xxx//idc/groups/public/documents/communication/pel_00236101.pdf. Presbyterian will provide material that contains in a clear, conspicuous and readily understandable form, a full and fair disclosure of the plan’s benefits, limitations, exclusions, conditions of eligibility and prior authorization requirements, within a reasonable time after enrollment and at subsequent periodic times as appropriate.‌ The Formulary can change throughout the year. Some reasons why it can change include: • New drugs are approved • Existing drugs are removed from the market • Prescription drugs may become available over the counter (without a prescription) • Brand-name drugs lose patent protection and generic versions become available. • Changes based on new clinical guidelines If we remove drugs from our Formulary, add quantity limits, prior authorization, and/or step therapy restrictions on a drug; or move a drug to a higher Cost-Sharing tier, we must notify affected members of the change at least 60-days before the change becomes effective.

Scans in an Outpatient Setting. Positron Emission Tomography (PET) is a noninvasive diagnostic imaging procedure that quantifies biochemical processes in living tissue. Positron Emission Tomography (PET) scans in an outpatient setting require Prior Authorization. This benefit has one or more exclusions as specified in the Exclusions Section. Practitioner/Provider services are those services that are reasonably required to maintain good health. Practitioner/Provider services include, but are not limited to, periodic examinations and office visits by: • A licensed Practitioner/Provider • Specialist services provided by other Health Care Professionals who are licensed to practice, are certified, and practicing as authorized by applicable law or authority • A medical group • An independent practice association • Other authority authorized by applicable state law Some Practitioner/Provider services require Prior Authorization. Refer to the Prior Authorization Section for Prior Authorization requirements. This Benefit includes, but not limited to, consultation and Health Care Services and supplies provided by your Practitioner/Provider as shown below: • Office visits/telemedicine visits provided by a qualified Practitioner/Provider. • Video Visits provided online between a designated Practitioner/Provider and patient about non-urgent healthcare matters. • Outpatient surgery and Inpatient surgery including necessary anesthesia services. Anesthesia may include hypnotherapyHypnotherapy is Covered as part of anesthesia preparation. • Hospital and Skilled Nursing Facility visits as part of continued supervision of Covered care‌‌ care • Allergy Services, including testing and serum • Sterilization procedures • Student Health Centers: Dependent Students attending school either in New Mexico or outside New Mexico may receive care through their Primary Care Physician or at the Student Health Center. A Prior Authorization is not needed prior to receiving care from the Student Health Center. Services provided outside of the Student Health Center are limited to Medically Necessary Covered services for the initial care or treatment of an Emergency Health Care Service or Urgent Care situation. • Second medical opinions. Cost Sharing will apply when you or your Practitioner/Provider requests the second medical opinion. Cost Sharing will not apply if we require a second medical opinion to evaluate the medical appropriateness of a diagnosis or service. This benefit has one or more exclusions as specified in the Exclusions Section. Outpatient Prescription Drugs are a Covered Benefit when prescribed by your Provider. Refer to your Formulary for information on the approved Prescription Drugs. For a complete list of these drugs, please see the Health Insurance Exchange Metal Level Plan Formulary list at xxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00236101.pdf. We will provide Coverage for preventive medications and products as defined by the Affordable Care Act (ACA) if you receive these services from our In-network Practitioner/Providers, without Cost Sharing regardless of sex assigned at birth, gender identity, or gender of the individual. Preventive medications are used for the management and prevention of complications from conditions such as high blood pressure, high cholesterol, diabetes, asthma, osteoporosis, heart attack and stroke. For prevention medications (including over-the-counter medications) or products to be covered, you’ll need to get a prescription from your Provider. Visit the Formulary listing at xxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00236101.pdf. Preventive medications will be listed as $0 Copay per PPACA. For a complete list of these preferred products, please see the Presbyterian Pharmacy website at xxxx://xxxx.xxx.xxx/idc/groups/public/@phs/@php/documents/phscontent/pel_00000000.pdf You can call our Presbyterian Customer Service Center at (000) 000-0000 or 0-000-000-0000, Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call our TTY line at If the following drugs are covered when prescribed by your provider and when purchased at an In-network Pharmacy. Refer to your Formulary for information on the approved Prescription Drugs/Medications. • Medically Necessary prescription nutritional supplements for prenatal care for up to a 90- day supply up to the maximum dosing recommended by the manufacturer. • Preferred insulin and diabetic oral agents for controlling blood sugar levels for up to a 90- day supply up to the maximum dosing recommended by the manufacturer. • Immunosuppressant drugs following transplant surgery for up to a 90-day supply up to the maximum dosing recommended by the manufacturer. • Special Medical Foods used in treatment to compensate and maintain adequate nutritional status for genetic Inborn Errors of Metabolism (IEM). These Special Medical Foods require Prior Authorization. • Smoking Cessation Pharmacotherapy. Formulary drugs for up to a 90-day supply up to the maximum dosing recommended by the manufacturer. Smoking cessation is limited to two 90-day courses of treatment per contract year. A drug Formulary, or preferred drug list, is a continually updated list of medications and related products supported by current evidence-based medicine, judgment of physicians, pharmacists and other experts in the diagnosis and treatment of disease and preservation of health. The primary purpose of the Formulary is to encourage the use of safe, effective and most affordable medications. Presbyterian Health Plan administers a closed Formulary, which means that non-formulary drugs are not routinely reimbursed by the plan. Medical exception policies provide access to non-formulary medications when Medical Necessity is established. The medications listed on the Formulary are subject to change pursuant to the management activities of Presbyterian Health Plan. For the most up-to-date Formulary drug information visit xxxx://xxxx.xxx.xxx//idc/groups/public/documents/communication/pel_00236101.pdf. Presbyterian will provide material that contains in a clear, conspicuous and readily understandable form, a full and fair disclosure of the plan’s benefits, limitations, exclusions, conditions of eligibility and prior authorization requirements, within a reasonable time after enrollment and at subsequent periodic times as appropriate. The Formulary can change throughout the year. Some reasons why it can change include: • New drugs are approved • Existing drugs are removed from the market • Prescription drugs may become available over-the-counter (without a prescription) • Brand-name drugs lose patent protection and generic versions become available. • Changes based on new clinical guidelines If we remove drugs from our Formulary, add quantity limits, prior authorization, and/or step therapy restrictions on a drug; or move a drug to a higher Cost-Sharing tier, we must notify affected members of the change at least 60-days before the change becomes effective.

Scans in an Outpatient Setting. Positron Emission Tomography (PET) is a noninvasive diagnostic imaging procedure that quantifies biochemical processes in living tissue. Positron Emission Tomography (PET) scans in an outpatient setting require Prior Authorization. This benefit has one or more exclusions as specified in the Exclusions Section. Practitioner/Provider services are those services that are reasonably required to maintain good health. Practitioner/Provider services include, but are not limited to, periodic examinations and office visits by: • A licensed Practitioner/Provider • Specialist services provided by other Health Care Healthcare Professionals who are licensed to practice, are certified, and practicing as authorized by applicable law or authority • A medical group • An independent practice association • Other authority authorized by applicable state law law‌‌ Some Practitioner/Provider services require Prior Authorization. Refer to the Prior Authorization Section for Prior Authorization requirements. This Benefit includes, but not limited to, consultation and Health Care Healthcare Services and supplies provided by your Practitioner/Provider as shown below: • Office visits/telemedicine visits provided by a qualified Practitioner/Provider. • PHP Video Visits provided online between a designated Practitioner/Provider and patient about non-urgent healthcare matters. PHP Video Visits utilize MeMD’s nationwide network of Providers and are $0 for all members that are not on a qualified high-deductible plan. • Telehealth appointments through video or phone are with a network Provider, including Presbyterian Medical Group Providers. • Online visits are an online medical interview followed by a response from a Presbyterian Medical Group Provider. They are $0 for all members that are not on a qualified high-deductible plan. • Outpatient surgery and Inpatient surgery including necessary anesthesia services. Anesthesia may include hypnotherapyHypnotherapy is Covered as part of anesthesia preparation. • Hospital and Skilled Nursing Facility visits as part of continued supervision of Covered care‌‌ care • Allergy Services, including testing and serum • Sterilization procedures • Student Health Centers: Dependent Students attending school either in New Mexico or outside New Mexico may receive care through their Primary Care Physician or at the Student Health Center. A Prior Authorization is not needed prior to receiving care from the Student Health Center. Services provided outside of the Student Health Center are limited to Medically Necessary Covered services for the initial care or treatment of an Emergency Health Care Service or Urgent Care situation. • Second medical opinions. Cost Sharing will apply when you or your Practitioner/Provider requests the second medical opinion. Cost Sharing will not apply if we require a second medical opinion to evaluate the medical appropriateness of a diagnosis or service. This benefit has one or more exclusions as specified in the Exclusions Section.

Scans in an Outpatient Setting. Positron Emission Tomography (PET) is a noninvasive diagnostic imaging procedure that quantifies biochemical processes in living tissue. Positron Emission Tomography (PET) scans in an outpatient setting require Prior Authorization. This benefit has one or more exclusions as specified in the Exclusions Section. Practitioner/Provider services are those services that are reasonably required to maintain good health. Practitioner/Provider services include, but are not limited to, periodic examinations and office visits by: • A licensed Practitioner/Provider • Specialist services provided by other Health Care Healthcare Professionals who are licensed to practice, are certified, and practicing as authorized by applicable law or authority • A medical group • An independent practice association • Other authority authorized by applicable state law Some Practitioner/Provider services require Prior Authorization. Refer to the Prior Authorization Section for Prior Authorization requirements. This Benefit includes, but not limited to, consultation and Health Care Healthcare Services and supplies provided by your Practitioner/Provider as shown below: • Office visits/telemedicine visits provided by a qualified Practitioner/Provider. Provider • PHP Video Visits provided online between a designated Practitioner/Provider and patient about non-urgent healthcare matters. PHP Video Visits utilizes Walmart Health Virtual Care’s nationwide network of Providers • Telehealth appointments through video or phone are with a network Provider, including Presbyterian Medical Group Providers • Online visits are an online medical interview followed by a response from a Presbyterian Medical Group Provider • behavioral health services will be provided via telemedicine on the same terms as physical health services in compliance with the telemedicine parity and mental health parity laws • Outpatient surgery and Inpatient surgery including necessary anesthesia services. Anesthesia may include hypnotherapy. hypnotherapy • Hospital and Skilled Nursing Facility visits as part of continued supervision of Covered care‌‌ care • Allergy Services, including testing and serum • Sterilization procedures • Student Health Centers: Dependent Students attending school either in New Mexico or outside New Mexico may receive care through their Primary Care Physician Provider or at the Student Health Center. A Prior Authorization is not needed prior to receiving care from the Student Health Center. Services provided outside of the Student Health Center are limited to Medically Necessary Covered services for the initial care or treatment of an Emergency Health Care Healthcare Service or Urgent Care situation. situation • Second medical opinions. Cost Sharing will apply when you or your Practitioner/Provider requests the second medical opinion. Cost Sharing will not apply if we require a second medical opinion to evaluate the medical appropriateness of a diagnosis or service. service This benefit has one or more exclusions as specified in the Exclusions Section. Outpatient Prescription Drugs are a Covered Benefit when prescribed by your Provider. Refer to your Formulary for information on the approved Prescription Drugs. For a complete list of these drugs, please see the Presbyterian Commercial 4-Tier Formulary list at xxxxx://xxxxxx.xxxxxxxxxxxxxxxxxx.xxx/Search.aspx?siteCode=0322075909. We will provide Coverage for preventive medications and products as defined by the Affordable Care Act (ACA) if you receive these services from our In-network Practitioners/Providers, without Cost Sharing regardless of sex assigned at birth, gender identity, or gender of the individual. Preventive medications are used for the management and prevention of complications from conditions such as high blood pressure, high cholesterol, diabetes, asthma, osteoporosis, heart attack and stroke.

Scans in an Outpatient Setting. Positron Emission Tomography (PET) is a noninvasive diagnostic imaging procedure that quantifies biochemical processes in living tissue. Positron Emission Tomography (PET) scans in an outpatient setting require Prior Authorization. This benefit has one or more exclusions as specified in the Exclusions Section. Practitioner/Provider services are those services that are reasonably required to maintain good health. Practitioner/Provider services include, but are not limited to, periodic examinations and office visits by: • A licensed Practitioner/Provider • Specialist services provided by other Health Care Healthcare Professionals who are licensed to practice, are certified, and practicing as authorized by applicable law or authority • A medical group • An independent practice association • Other authority authorized by applicable state law law‌‌ Some Practitioner/Provider services require Prior Authorization. Refer to the Prior Authorization Section for Prior Authorization requirements. This Benefit includes, but not limited to, consultation and Health Care Healthcare Services and supplies provided by your Practitioner/Provider as shown below: • Office visits/telemedicine visits provided by a qualified Practitioner/Provider. • PHP Video Visits provided online between a designated Practitioner/Provider and patient about non-urgent healthcare matters. PHP Video Visits utilize MeMD’s nationwide network of Providers. • Telehealth appointments through video or phone are with a network Provider, including Presbyterian Medical Group Providers. • Online Visits are an online medical interview followed by a response from a Presbyterian Medical Group Provider. • Outpatient surgery and Inpatient surgery including necessary anesthesia services. Anesthesia may include hypnotherapyHypnotherapy is Covered as part of anesthesia preparation. • Hospital and Skilled Nursing Facility visits as part of continued supervision of Covered care‌‌ care • Allergy Services, including testing and serum • Sterilization procedures • Student Health Centers: Dependent Students attending school either in New Mexico or outside New Mexico may receive care through their Primary Care Physician or at the Student Health Center. A Prior Authorization is not needed prior to receiving care from the Student Health Center. Services provided outside of the Student Health Center are limited to Medically Necessary Covered services for the initial care or treatment of an Emergency Health Care Service or Urgent Care situation. • Second medical opinions. Cost Sharing will apply when you or your Practitioner/Provider requests the second medical opinion. Cost Sharing will not apply if we require a second medical opinion to evaluate the medical appropriateness of a diagnosis or service. This benefit has one or more exclusions as specified in the Exclusions Section.

Scans in an Outpatient Setting. Positron Emission Tomography (PET) is a noninvasive diagnostic imaging procedure that quantifies biochemical processes in living tissue. Positron Emission Tomography (PET) scans in an outpatient setting require Prior Authorization. This benefit has one or more exclusions as specified in the Exclusions Section. Practitioner/Provider services are those services that are reasonably required to maintain good health. Practitioner/Provider services include, but are not limited to, periodic examinations and office visits by: • A licensed Practitioner/Provider • Specialist services provided by other Health Care Healthcare Professionals who are licensed to practice, are certified, and practicing as authorized by applicable law or authority • A medical group • An independent practice association • Other authority authorized by applicable state law Some Practitioner/Provider services require Prior Authorization. Refer to the Prior Authorization Section for Prior Authorization requirements. This Benefit includes, but not limited to, consultation and Health Care Healthcare Services and supplies provided by your Practitioner/Provider as shown below: • Office visits/telemedicine visits provided by a qualified Practitioner/Provider. • PHP Video Visits provided online between a designated Practitioner/Provider and patient about non-urgent healthcare matters. • PHP Video Visits utilize MeMD’s nationwide network of Providers are $0 for all members that are not on a qualified high-deductible plan. • Telehealth appointments through video or phone are with a network Provider, including Presbyterian Medical Group. • Online visits are an online medical interview followed by a response from a Presbyterian Medical Group Provider. They are $0 for all members that are not on a qualified high- deductible plan. • Outpatient surgery and Inpatient surgery including necessary anesthesia services. Anesthesia may include hypnotherapy. • Hospital and Skilled Nursing Facility visits as part of continued supervision of Covered care‌‌ care • Allergy Services, including testing and serum • Sterilization procedures • Student Health Centers: Dependent Students attending school either in New Mexico the 5-county area or outside New Mexico the 5-county area may receive care through their Primary Care Physician or at the Student Health Center. A Prior Authorization is not needed prior to receiving care from the Student Health Center. Services provided outside of the Student Health Center are limited to Medically Necessary Covered services for the initial care or treatment of an Emergency Health Care Healthcare Service or Urgent Care situation. • Second medical opinions. Cost Sharing will apply when you or your Practitioner/Provider requests the second medical opinion. Cost Sharing will not apply if we require a second medical opinion to evaluate the medical appropriateness of a diagnosis or service. This benefit has one or more exclusions as specified in the Exclusions Section.

Scans in an Outpatient Setting. Positron Emission Tomography (PET) is a noninvasive diagnostic imaging procedure that quantifies biochemical processes in living tissue. Positron Emission Tomography (PET) scans in an outpatient setting require Prior Authorization. This benefit has one or more exclusions as specified in the Exclusions Section. Practitioner/Provider services are those services that are reasonably required to maintain good health. Practitioner/Provider services include, but are not limited to, periodic examinations and office visits by: • A licensed Practitioner/Provider • Specialist services provided by other Health Care Professionals who are licensed to practice, are certified, and practicing as authorized by applicable law or authority • A medical group • An independent practice association • Other authority authorized by applicable state law Some Practitioner/Provider services require Prior Authorization. Refer to the Prior Authorization Section for Prior Authorization requirements. This Benefit includes, but not limited to, consultation and Health Care Services and supplies provided by your Practitioner/Provider as shown below: • Office visits/telemedicine visits provided by a qualified Practitioner/Provider. • Video Visits provided online between a designated Practitioner/Provider and patient about non-urgent healthcare matters. • Outpatient surgery and Inpatient surgery including necessary anesthesia services. Anesthesia may include hypnotherapyHypnotherapy is Covered as part of anesthesia preparation. • Hospital and Skilled Nursing Facility visits as part of continued supervision of Covered care‌‌ care • Allergy Services, including testing and serum • Sterilization procedures • Student Health Centers: Dependent Students attending school either in New Mexico or outside New Mexico may receive care through their Primary Care Physician or at the Student Health Center. A Prior Authorization is not needed prior to receiving care from the Student Health Center. Services provided outside of the Student Health Center are limited to Medically Necessary Covered services for the initial care or treatment of an Emergency Health Care Service or Urgent Care situation. • Second medical opinions. Cost Sharing will apply when you or your Practitioner/Provider requests the second medical opinion. Cost Sharing will not apply if we require a second medical opinion to evaluate the medical appropriateness of a diagnosis or service. This benefit has one or more exclusions as specified in the Exclusions Section. Outpatient Prescription Drugs are a Covered Benefit when prescribed by your Provider. Refer to your Formulary for information on the approved Prescription Drugs. For a complete list of these drugs, please see the Health Insurance Exchange Metal Level Plan Formulary list at xxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00236101.pdf. We will provide Coverage for preventive medications and products as defined by the Affordable Care Act (ACA) if you receive these services from our In-network Practitioners/Providers without cost sharing regardless of sex assigned at birth, gender identity, or gender of the individual. Preventive medications are used for the management and prevention of complications from conditions such as high blood pressure, high cholesterol, diabetes, asthma, osteoporosis, heart attack and stroke. For preventive medications (including over-the-counter medications) or products to be covered, you’ll need to get a prescription from your Provider. Visit the Formulary listing at xxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00236101.pdf. Preventive medications will be listed as $0 Copay per PPACA. For a complete list of these preferred products, please see the Presbyterian Pharmacy website at For more information contact our Presbyterian Customer Service Center at (000) 000-0000 or 0-000-000-0000, Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call our TTY line at 711. The following drugs are covered when prescribed by your provider and when purchased at an In- network Pharmacy. Refer to your Formulary for information on the approved Prescription Drugs/Medications. • Medically Necessary prescription nutritional supplements for prenatal care for up to a 90- day supply up to the maximum dosing recommended by the manufacturer. • Preferred insulin and diabetic oral agents for controlling blood sugar levels for up to a 90- day supply up to the maximum dosing by the manufacturer. • Immunosuppressant drugs following transplant surgery for up to a 90-day supply up to the maximum dosing recommended by the manufacturer. • Special Medical Foods used in treatment to compensate and maintain adequate nutritional status for genetic Inborn Errors of Metabolism (IEM). These Special Medical Foods require Prior Authorization. • Smoking Cessation Pharmacotherapy. Formulary drugs for up to a 90-day supply up to the maximum dosing recommended by the manufacturer. Smoking cessation is limited to two 90-day courses of treatment per contract year. A drug Formulary, or preferred drug list, is a continually updated list of medications and related products supported by current evidence-based medicine, judgement of physicians, pharmacists and other experts in the diagnosis and treatment of disease and preservation of health. The primary purpose of the Formulary is to encourage the use of safe, effective and most affordable medications. Presbyterian Insurance Company, Inc., administers a closed Formulary, which means that non-formulary drugs are not routinely reimbursed by the plan. Medical exception policies provide access to non-formulary medication when Medical Necessity is established. The medications listed on the Formulary are subject to change pursuant to the management activities of Presbyterian Insurance Company, Inc. For the most up-to-date Formulary drug information visit xxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00236101.pdf. Presbyterian will provide material that contains in a clear, conspicuous and readily understandable form, a full and fair disclosure of the plan’s benefits, limitations, exclusions, conditions of eligibility and prior authorization requirements, within a reasonable time after enrollment and at subsequent periodic times as appropriate. The Formulary can change throughout the year. Some reasons why it can change include: • New drugs are approved • Existing drugs are removed from the market. • Prescription drugs may become available over the counter (without a prescription) • Brand-name drugs lose patent protection and generic versions become available • Changes based on new clinical guidelines If we remove drugs from our Formulary, add quantity limits, prior authorization, and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective.