Common use of Specialty Prescription Drugs (+ Clause in Contracts

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy(+): Copayment applies per each 30-day supply or applies per recommended treatment interval. Tier 4: $150 - After deductible Not Covered Tier 5: $300 - After deductible Not Covered When purchased at a Retail Pharmacy(+): Copayment applies per each 30-day supply or applies per recommended treatment interval. Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 4: 50% - After deductible Not Covered Tier 5: 50% - After deductible Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Infertility Prescription Drugs - Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% - After deductible Not Covered Tier 2: 20% - After deductible Not Covered Tier 3: 20% - After deductible Not Covered When purchased at a Specialty Pharmacy(+) Tier 4: 20% - After deductible Not Covered Tier 5: 20% - After deductible Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy(+): Copayment applies per each 30-day supply or applies per recommended treatment interval. Tier 4: $150 - After deductible Not Covered Tier 5: $300 150 - After deductible Not Covered When purchased at a Retail Pharmacy(+): Tier 5: 50% - After deductible Not Covered Copayment applies per each 30-day supply or applies per recommended treatment interval. Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 4: 50% - After deductible Not Covered Tier 5: 50% - After deductible Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Infertility Prescription Drugs - Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% - After deductible Not Covered Tier 2: 20% - After deductible Not Covered Tier 3: 20% - After deductible Not Covered When purchased at a Specialty Pharmacy(+) Tier 4: 20% - After deductible Not Covered When purchased at a Specialty Pharmacy(+) Tier 5: 20% - After deductible Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy(+): Copayment applies per each 30-day supply or applies per recommended treatment interval. Tier 4: $150 - After deductible Not Covered Tier 5: $300 - After deductible 100 Not Covered When purchased at a Retail Pharmacy(+): Tier 5: 50% Not Covered Copayment applies per each 30-day supply or applies per recommended treatment interval. Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 4: 50% - After deductible Not Covered Tier 5: 50% - After deductible Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Infertility Prescription Drugs - Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% - After deductible Not Covered Tier 2: 20% - After deductible Not Covered Tier 3: 20% - After deductible Not Covered Tier 4: 20% Not Covered When purchased at a Specialty Pharmacy(+) Tier 4: 20% - After deductible Not Covered Tier 5: 20% - After deductible Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy(+): Tier 5: $100 - After deductible Not Covered Copayment applies per each 30-day supply or applies per recommended treatment interval. Tier 4: $150 - After deductible Not Covered Tier 5: $300 - After deductible Not Covered When purchased at a Retail Pharmacy(+): Tier 5: 50% - After deductible Not Covered Copayment applies per each 30-day supply or applies per recommended treatment interval. Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 4: 50% - After deductible Not Covered Tier 5: 50% - After deductible Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Infertility Prescription Drugs - Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% - After deductible Not Covered Tier 2: 20% Not Covered Tier 3: 20% - After deductible Not Covered Tier 34: 20% - After deductible Not Covered When purchased at a Specialty Pharmacy(+) Tier 45: 20% - After deductible Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% - After deductible Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy(+Pharmacy (+): Copayment For maintenance and non-maintenance prescription drugs, a copayment applies per for each 30-day supply period (or applies per recommended treatment intervalportion thereof) within the prescribed dosing period. Tier 4: $150 - After after deductible Not Covered Tier 5: $300 - After after deductible Not Covered When purchased at a Retail Pharmacy(+Pharmacy (+): Copayment For maintenance and non-maintenance prescription drugs, a copayment applies per for each 30-day supply period (or applies per recommended treatment intervalportion thereof) within the prescribed dosing period. Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 4: 50% - After after deductible Not Covered Tier 5: 50% - After after deductible Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Infertility Prescription Drugs - Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% - After deductible Not Covered Tier 2: 20% - After deductible Not Covered Tier 3: 20% - After deductible Not Covered When purchased at a Specialty Pharmacy(+) Tier 4: 20% - After deductible Not Covered Tier 5: 20% - After deductible Not Covered.