Common use of YOUR COST FOR PRESCRIPTION DRUGS Clause in Contracts

YOUR COST FOR PRESCRIPTION DRUGS. How Your Cost is Determined The amount that you are responsible for is based upon the drug tier as described below and shown in the Benefit Highlights section of this Certificate • Tier 1 - includes mostly Generic Drugs and may contain some Brand Name Drugs. • Tier 2 - includes mostly Preferred Brand Name Drugs and may contain some Generic Drugs. • Tier 3 - includes mostly Non-Preferred Brand Name Drugs and may contain some Generic Drugs. To verify your payment amount for a drug, visit the Plan's website at xxx.xxxxxx.xxx and log into Blue Access for Members or call the number on the back of your identification card. Benefits will be provided as shown in the Benefit Highlights section of this Certificate. Out‐of‐Pocket Expense Limit Expenses incurred by you for Covered Services under this benefit section will be applied towards the Covered Services Expense Limitation described in the OTHER THINGS YOU SHOULD KNOW section of this Certificate. If dur­ ing one calendar year your Covered Services Expense Limitation is reached, benefits will be available for any additional eligible Claims for drugs and dia­ betic supplies obtained during that calendar year and will be paid in full at no cost to you. If during one calendar year, your out‐of‐pocket expense (the amount remaining unpaid after benefits have been provided) for Outpatient prescription drugs and diabetic supplies equals $500, any additional eligible Claims for Outpatient pre­ scription drugs and diabetic supplies during that calendar year will be paid in full at no cost to you. If you have Family Coverage and your out‐of‐pocket expense (the amount re­ maining unpaid after benefits have been provided) for Outpatient prescription drugs and diabetic supplies equals $1,000 during one calendar year, then for the rest of that calendar year, all other family members will have benefits paid in full at no cost to them. A family member may not apply more than the individu­ al out‐of‐pocket expense limit toward this amount.

YOUR COST FOR PRESCRIPTION DRUGS. How Your Cost is Determined The amount that you are responsible for is based upon the drug tier as described below and shown in the Benefit Highlights BENEFIT HIGHLIGHTS section of this Certificate Certificate. • Tier 1 - includes mostly Generic Drugs and may contain some Brand Name Drugs. • Tier 2 - includes mostly Preferred Brand Name Drugs and may contain some Generic Drugs. • Tier 3 - includes mostly Non-Preferred Non‐Preferred Brand Name Drugs and may contain some Generic Drugs. If you or your Provider request a Brand Name Drug when a Generic Drug is available, you will pay the applicable Copayment Amount and/or Coinsurance based on current tier of Brand Name Drug plus the difference between the allowable amount of the Brand Name Drug and the allowable amount of the Generic Drug, except as otherwise provided in this Certificate. You may not be required to pay the difference in cost between the Allowable Amount of the Brand Name Drug and the Allowable Amount of the Generic Drug if there is a medical reason (e.g., adverse event) you need to take the Brand Name Drug and certain criteria are met. Your Provider can submit a request to waive the difference in cost between the Allowable Amount of the Brand Name Drug and Allowable Amount of the Generic Drug. In order for this request to be reviewed, your Provider must send in a MedWatch form to the Food and Drug Administration (FDA) to let them know the issues you experienced with the generic equivalent. Your Physician must provide a copy of this form when requesting the waiver. The FDA MedWatch form is used to document adverse events, therapeutic inequivalence failure, product quality problems, and product problems, and product use/medication error. This form is available on the FDA website. If the waiver is granted, applicable Copayment Amount and/or Coinsurance Amounts will still apply. For additional information, contact the customer service number on the back of your identification card or visit xxx.xxxxxx.xxx To verify obtain additional information about your payment amount benefits for a drug, visit the Plan's website at xxx.xxxxxx.xxx and log into Blue Access for Members or call the number on the back of your identification card. Benefits will be provided as shown in the Benefit Highlights BENEFIT HIGHLIGHTS section of this Certificate. Out‐of‐Pocket Expense Limit Expenses incurred by you for Covered Services under this benefit section will be applied towards the Covered Services Expense Limitation described in the OTHER THINGS YOU SHOULD KNOW section of this Certificate. If dur­ ing one calendar year your Covered Services Expense Limitation is reached, benefits will be available for any additional eligible Claims for drugs and dia­ betic supplies obtained during that calendar year and will be paid in full at no cost to you. If during one calendar year, your out‐of‐pocket expense (the amount remaining unpaid after benefits have been provided) for Outpatient prescription drugs and diabetic supplies equals $5005,100, any additional eligible Claims for Outpatient pre­ scription prescription drugs and diabetic supplies during that calendar year will be paid in full at no cost to you. If you have Family Coverage and your out‐of‐pocket expense (the amount re­ maining remaining unpaid after benefits have been provided) for Outpatient prescription drugs and diabetic supplies equals $1,000 10,200 during one calendar year, year then for the rest of that calendar year, year all other family members will have benefits paid in full at no cost to them. A family member may not apply more than the individu­ al out‐of‐pocket If a Covered Drug was paid for using any third-party payments, financial assistance, discount, product voucher, or other reduction in out-of-pocket expenses made by or on your behalf, that amount will be applied to your program deductible or out-of-pocket expense limit toward this amountlimit.

YOUR COST FOR PRESCRIPTION DRUGS. How Your Cost is Determined The amount that you are responsible for is based upon the drug tier as described below and shown in the Benefit Highlights section of this Certificate • Tier 1 - includes mostly Generic Drugs and may contain some Brand Name Drugs. • Tier 2 - includes mostly Preferred Brand Name Drugs and may contain some Generic Drugs. • Tier 3 - includes mostly Non-Preferred Brand Name Drugs and may contain some Generic Drugs. To verify your payment amount for a drug, visit the Plan's website at xxx.xxxxxx.xxx and log into Blue Access for Members or call the number on the back of your identification card. Benefits will be provided as shown in the Benefit Highlights section of this Certificate. Out‐of‐Pocket Expense Limit Expenses incurred by you for Covered Services under this benefit section will be applied towards the Covered Services Expense Limitation described in the OTHER THINGS YOU SHOULD KNOW section of this Certificate. If dur­ ing one calendar year your Covered Services Expense Limitation is reached, benefits will be available for any additional eligible Claims for drugs and dia­ betic supplies obtained during that calendar year and will be paid in full at no cost to you. If during one calendar year, your out‐of‐pocket expense (the amount remaining unpaid after benefits have been provided) for Outpatient prescription drugs and diabetic supplies equals $5003,000, any additional eligible Claims for Outpatient pre­ scription prescription drugs and diabetic supplies during that calendar year will be paid in full at no cost to you. If you have Family Coverage and your out‐of‐pocket expense (the amount re­ maining unpaid after benefits have been provided) for Outpatient prescription drugs and diabetic supplies equals $1,000 6,000 during one calendar year, then for the rest of that calendar year, all other family members will have benefits paid in full at no cost to them. A family member may not apply more than the individu­ al out‐of‐pocket expense limit toward this amount.

YOUR COST FOR PRESCRIPTION DRUGS. How Your Cost is Determined The amount that you are responsible for is based upon the drug tier as described below and shown in the Benefit Highlights section of this Certificate • Tier 1 - includes mostly Generic Drugs and may contain some Brand Name Drugs. • Tier 2 - includes mostly Preferred Brand Name Drugs and may contain some Generic Drugs. • Tier 3 - includes mostly Non-Preferred Brand Name Drugs and may contain some Generic Drugs. To verify your payment amount for a drug, visit the Plan's website at xxx.xxxxxx.xxx and log into Blue Access for Members or call the number on the back of your identification card. Benefits will be provided as shown in the Benefit Highlights section of this Certificate. Out‐of‐Pocket Expense Limit Expenses incurred by you for Covered Services under this benefit section will be applied towards the Covered Services Expense Limitation described in the OTHER THINGS YOU SHOULD KNOW section of this Certificate. If dur­ ing one calendar year your Covered Services Expense Limitation is reached, benefits will be available for any additional eligible Claims for drugs and dia­ betic supplies obtained during that calendar year and will be paid in full at no cost to you. If during one calendar year, your out‐of‐pocket expense (the amount remaining unpaid after benefits have been provided) for Outpatient prescription drugs and diabetic supplies equals $5005,350, any additional eligible Claims for Outpatient pre­ scription prescription drugs and diabetic supplies during that calendar year will be paid in full at no cost to you. If you have Family Coverage and your out‐of‐pocket expense (the amount re­ maining unpaid after benefits have been provided) for Outpatient prescription drugs and diabetic supplies equals $1,000 10,700 during one calendar year, then for the rest of that calendar year, all other family members will have benefits paid in full at no cost to them. A family member may not apply more than the individu­ al out‐of‐pocket expense limit toward this amount.

YOUR COST FOR PRESCRIPTION DRUGS. How Your Cost is Determined The amount that you are responsible for is based upon the drug tier as described below and shown in the Benefit Highlights section of this Certificate • Tier 1 - includes mostly Generic Drugs and may contain some Brand Name Drugs. • Tier 2 - includes mostly Preferred Brand Name Drugs and may contain some Generic Drugs. • Tier 3 - includes mostly Non-Preferred Brand Name Drugs and may contain some Generic Drugs. To verify your payment amount for a drug, visit the Plan's website at xxx.xxxxxx.xxx and log into Blue Access for Members or call the number on the back of your identification card. Benefits will be provided as shown in the Benefit Highlights section of this Certificate. Out‐of‐Pocket Expense Limit Expenses incurred by you for Covered Services under this benefit section will be applied towards the Covered Services Expense Limitation described in the OTHER THINGS YOU SHOULD KNOW section of this Certificate. If dur­ ing one calendar year your Covered Services Expense Limitation is reached, benefits will be available for any additional eligible Claims for drugs and dia­ betic supplies obtained during that calendar year and will be paid in full at no cost to you. If during one calendar year, your out‐of‐pocket expense (the amount remaining unpaid after benefits have been provided) for Outpatient prescription drugs and diabetic supplies equals $5001,500, any additional eligible Claims for Outpatient pre­ scription prescription drugs and diabetic supplies during that calendar year will be paid in full at no cost to you. If you have Family Coverage and your out‐of‐pocket expense (the amount re­ maining unpaid after benefits have been provided) for Outpatient prescription drugs and diabetic supplies equals $1,000 10,200 during one calendar year, then for the rest of that calendar year, all other family members will have benefits paid in full at no cost to them. A family member may not apply more than the individu­ al out‐of‐pocket expense limit toward this amount.

YOUR COST FOR PRESCRIPTION DRUGS. How Your Cost is Determined The amount that you are responsible for is based upon the drug tier as described below and shown in the Benefit Highlights section of this Certificate • Tier 1 - includes mostly Generic Drugs and may contain some Brand Name Drugs. • Tier 2 - includes mostly Preferred Brand Name Drugs and may contain some Generic Drugs. • Tier 3 - includes mostly Non-Preferred Brand Name Drugs and may contain some Generic Drugs. To verify your payment amount for a drug, visit the Plan's website at xxx.xxxxxx.xxx and log into Blue Access for Members or call the number on the back of your identification card. Benefits will be provided as shown in the Benefit Highlights section of this Certificate. Out‐of‐Pocket Expense Limit Expenses incurred by you for Covered Services under this benefit section will be applied towards the Covered Services Expense Limitation described in the OTHER THINGS YOU SHOULD KNOW section of this Certificate. If dur­ ing one calendar year your Covered Services Expense Limitation is reached, benefits will be available for any additional eligible Claims for drugs and dia­ betic supplies obtained during that calendar year and will be paid in full at no cost to you. If during one calendar year, your out‐of‐pocket expense (the amount remaining unpaid after benefits have been provided) for Outpatient prescription drugs and diabetic supplies equals $5001,000, any additional eligible Claims for Outpatient pre­ scription prescription drugs and diabetic supplies during that calendar year will be paid in full at no cost to you. If you have Family Coverage and your out‐of‐pocket expense (the amount re­ maining unpaid after benefits have been provided) for Outpatient prescription drugs and diabetic supplies equals $1,000 2,000 during one calendar year, then for the rest of that calendar year, all other family members will have benefits paid in full at no cost to them. A family member may not apply more than the individu­ al out‐of‐pocket expense limit toward this amount.

YOUR COST FOR PRESCRIPTION DRUGS. How Your Cost is Determined The amount that you are responsible for is based upon the drug tier as described below and shown in the Benefit Highlights section of this Certificate Certificate. • Tier 1 - includes mostly Generic Drugs and may contain some Brand Name Drugs. • Tier 2 - includes mostly Preferred Brand Name Drugs and may contain some Generic Drugs. • Tier 3 - includes mostly Non-Preferred Brand Name Drugs and may contain some Generic Drugs. • Tier 4 - includes Specialty Drugs and may contain some Generic Drugs. To verify get additional information about your payment amount benefits for a drug, visit the Plan's website at xxx.xxxxxx.xxx and log into Blue Access for Members or call the number on the back of your identification card. Benefits will be provided as shown in the Benefit Highlights section of this Certificate. Out‐of‐Pocket Expense Limit Expenses incurred by you for Covered Services under this benefit section will be applied towards the Covered Services Expense Limitation described in the OTHER THINGS YOU SHOULD KNOW section of this Certificate. If dur­ ing during one calendar year your Covered Services Expense Limitation is reached, benefits will be available for any additional eligible Claims for drugs and dia­ betic diabetic supplies obtained during that calendar year and will be paid in full at no cost to you. If during one calendar year, your out‐of‐pocket expense (the amount remaining unpaid after benefits have been provided) for Outpatient prescription drugs and diabetic supplies equals $5005,100, any additional eligible Claims for Outpatient pre­ scription prescription drugs and diabetic supplies during that calendar year will be paid in full at no cost to you. If you have Family Coverage and your out‐of‐pocket expense (the amount re­ maining remaining unpaid after benefits have been provided) for Outpatient prescription drugs and diabetic supplies equals $1,000 10,200 during one calendar year, then for the rest of that calendar year, all other family members will have benefits paid in full at no cost to them. A family member may not apply more than the individu­ al individual out‐of‐pocket expense limit toward this amount.

YOUR COST FOR PRESCRIPTION DRUGS. How Your Cost is Determined The amount that you are responsible for is based upon the drug tier as described below and shown in the Benefit Highlights section of this Certificate • Tier 1 - includes mostly Generic Drugs and may contain some Brand Name Drugs. • Tier 2 - includes mostly Preferred Brand Name Drugs and may contain some Generic Drugs. • Tier 3 - includes mostly Non-Preferred Brand Name Drugs and may contain some Generic Drugs. If you or your Provider requests a Brand Name Drug when a generic or thera- peutic equivalent is available, you will be responsible for the Non‐Preferred Brand Name Drug payment amount, plus the difference in cost between the Brand Name Drug and the generic equivalent, except as provided in this Certi- ficate. To verify your payment amount for a drug, visit the Plan's website at xxx.xxxxxx.xxx and log into Blue Access for Members or call the number on the back of your identification card. Benefits will be provided as shown in the Benefit Highlights section of this Certificate. Out‐of‐Pocket Expense Limit Expenses incurred by you for Covered Services under this benefit section will be applied towards the Covered Services Expense Limitation described in the OTHER THINGS YOU SHOULD KNOW section of this Certificate. If dur­ dur- ing one calendar year your Covered Services Expense Limitation is reached, benefits will be available for any additional eligible Claims for drugs and dia­ dia- betic supplies obtained during that calendar year and will be paid in full at no cost to you. If during one calendar year, your out‐of‐pocket expense (the amount remaining unpaid after benefits have been provided) for Outpatient prescription drugs and diabetic supplies equals $5002,000, any additional eligible Claims for Outpatient pre­ scription prescription drugs and diabetic supplies during that calendar year will be paid in full at no cost to you. If you have Family Coverage and your out‐of‐pocket expense (the amount re­ re- maining unpaid after benefits have been provided) for Outpatient prescription drugs and diabetic supplies equals $1,000 4,000 during one calendar year, then for the rest of that calendar year, all other family members will have benefits paid in full at no cost to them. A family member may not apply more than the individu­ individu- al out‐of‐pocket expense limit toward this amount.

YOUR COST FOR PRESCRIPTION DRUGS. How Your Cost is Determined The amount that you are responsible for is based upon the drug tier as described below and shown in the Benefit Highlights section of this Certificate • Tier 1 - includes mostly Generic Drugs and may contain some Brand Name Drugs. • Tier 2 - includes mostly Preferred Brand Name Drugs and may contain some Generic Drugs. • Tier 3 - includes mostly Non-Preferred Brand Name Drugs and may contain some Generic Drugs. If you or your Provider requests a Brand Name Drug when a generic or thera­ peutic equivalent is available, you will be responsible for the Non‐Preferred Brand Name Drug payment amount, plus the difference in cost between the Brand Name Drug and the generic equivalent, except as provided in this Certi­ ficate. To verify your payment amount for a drug, visit the Plan's website at xxx.xxxxxx.xxx and log into Blue Access for Members or call the number on the back of your identification card. Benefits will be provided as shown in the Benefit Highlights section of this Certificate. Out‐of‐Pocket Expense Limit Expenses incurred by you for Covered Services under this benefit section will be applied towards the Covered Services Expense Limitation described in the OTHER THINGS YOU SHOULD KNOW section of this Certificate. If dur­ ing one calendar year your Covered Services Expense Limitation is reached, benefits will be available for any additional eligible Claims for drugs and dia­ betic supplies obtained during that calendar year and will be paid in full at no cost to you. If during one calendar year, your out‐of‐pocket expense (the amount remaining unpaid after benefits have been provided) for Outpatient prescription drugs and diabetic supplies equals $5002,000, any additional eligible Claims for Outpatient pre­ scription prescription drugs and diabetic supplies during that calendar year will be paid in full at no cost to you. If you have Family Coverage and your out‐of‐pocket expense (the amount re­ maining unpaid after benefits have been provided) for Outpatient prescription drugs and diabetic supplies equals $1,000 4,000 during one calendar year, then for the rest of that calendar year, all other family members will have benefits paid in full at no cost to them. A family member may not apply more than the individu­ al out‐of‐pocket expense limit toward this amount.