Common use of Covered Drugs Clause in Contracts

Covered Drugs. Benefits for Medically Necessary Covered Drugs prescribed to treat You for a chronic, disabling, or life-threatening illness covered by HMO are available if the drug is on the applicable Drug List and has been approved by the United States Food and Drug Administration (FDA) for at least one indication and is recognized by the following for treatment of the indication for which the drug is prescribed: • a prescription drug reference compendium approved by the Texas Department of Insurance, or • substantially accepted peer-reviewed medical literature. For a list of Covered Drugs, You can access the website at xxxxx://xxx.xxxxxx.xxx/member/prescription-drug- plan-information/drug-lists or You can also contact customer service at the toll-free number on Your identification card. You are responsible for any Copayments for Covered Drugs shown in THE SCHEDULE OF COPAYMENTS AND Benefit Limits and pricing differences that may apply to the Covered Drug dispensed. Injectable Drugs. Injectable drugs approved by the FDA for self-administration are covered. Benefits will not be provided under PHARMACY BENEFITS for any self-administered drugs dispensed by a Physician. Diabetes Supplies for Diabetes Care. Insulin, insulin analogs, insulin pens, insulin syringes, needles, injection devices, glucagon emergency kits, lancets, lancet devices, glucose meter solution, test strips specified for use with a corresponding blood glucose monitor, visual reading strips and urine and blood testing strips, and tablets which test for glucose, ketones, and protein, and prescriptive and nonprescriptive oral agents for controlling blood sugar levels are covered. A separate Copayment will apply to each fill of a prescription purchased on the same day for insulin and insulin syringes. All supplies, including medications and equipment for the control of diabetes will be dispensed as written, unless substitution is approved by Your prescribing Physician or other Health Care Practitioner who issues the written order for the supplies or equipment. Preventive Care. Prescription and over-the-counter drugs which, have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force (“USPSTF”) (to be implemented in the quantities and within the time period allowed under applicable law) or as required by state law will be covered and will not be subject to any Copayment or dollar maximums. Select Vaccinations obtained through certain Participating Pharmacies. Benefits for select vaccinations are shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS. These vaccinations are available through certain Participating Pharmacies that have contracted with HMO to provide this service. To locate one of these Participating Pharmacies in the Pharmacy Vaccine Network in Your area and to determine which vaccinations are covered under this benefit, access the website at xxx.xxxxxx.xxx or contact customer service at the toll-free number on Your identification card. Each Participating Pharmacy included in the Pharmacy Vaccine Network that has contracted with HMO to provide this service may have age, scheduling, or other requirements that will apply, so you are encouraged to contact them in advance. Formulas for the Treatment of Phenylketonuria or Other Heritable Diseases. Dietary formulas necessary for the treatment of phenylketonuria or other heritable diseases are covered to the same extent as any other Covered Drug only on the orders of a Health Care Practitioner. Amino Acid-Based Elemental Formulas. Formulas, regardless of the formula delivery method, used for the diagnosis and treatment of: • Immunoglobulin E and non-immunoglobulin E mediated allergies to multiple food proteins; • Severe food protein-induced enterocolitis syndromes; • Eosinophilic disorders, as evidenced by the results of biopsy; and • Disorders affecting the absorptive surface, functional length, and motility of the gastrointestinal tract. A Prescription Order from your Health Care Practitioner is required.

Covered Drugs. Benefits for Medically Necessary Covered Drugs prescribed to treat You for a chronic, disabling, or life-threatening illness covered by HMO are available if the drug is on the applicable Drug List and has been approved by the United States Food and Drug Administration (FDA) for at least one indication and is recognized by the following for treatment of the indication for which the drug is prescribed: • a prescription drug reference compendium approved by the Texas Department of Insurance, ; or • substantially accepted peer-reviewed medical literature. For a list of Covered Drugs, You can access the website at xxxxx://xxx.xxxxxx.xxx/member/prescription-drug- plan-xxx.xxxxxx.xxx/xxxxxx/xxxxxxxxxxxx-xxxx-xxxx- information/drug-lists or You can also contact customer service at the toll-free number on Your identification card. You are responsible for any Copayments for Covered Drugs shown in THE SCHEDULE OF COPAYMENTS AND the Schedule of Copayments and Benefit Limits and pricing differences that may apply to the Covered Drug dispensed. Injectable Drugs. Injectable drugs approved by the FDA for self-administration are covered. Benefits will not be provided under PHARMACY BENEFITS for any self-administered drugs dispensed by a Physician. Diabetes Supplies for Diabetes Care. Insulin, insulin analogs, insulin pens, insulin syringes, needles, injection devices, glucagon emergency kits, lancets, lancet devices, glucose meter solution, test strips specified for use with a corresponding blood glucose monitor, visual reading strips and urine and blood testing strips, and tablets which test for glucose, ketones, and protein, and prescriptive and nonprescriptive oral agents for controlling blood sugar levels are covered. A separate Copayment will apply to each fill of a prescription purchased on the same day for insulin and insulin syringes. All supplies, including medications and equipment for the control of diabetes will be dispensed as written, unless substitution is approved by Your prescribing Physician or other Health Care Practitioner who issues the written order for the supplies or equipment. Preventive Care. Emergency Refills of Insulin or Insulin-Related Equipment and Supplies A pharmacist may exercise their professional judgement in refilling a Prescription and over-the-counter drugs which, have in effect a rating Order for Insulin or Insulin- Related Equipment or Supplies without the authorization of “A” or “B” the prescribing Health Care Practitioner in the current recommendations following situations: • the pharmacist is unable to contact your Health Care Practitioner after reasonable effort; • the pharmacist has documentation showing the patient was previously prescribed insulin or insulin-related equipment or supplies by a Health Care Practitioner; and • the pharmacist accesses the patient to determine whether the emergency refill is appropriate. The quantity of the United States Preventive Services Task Force (“USPSTF”) (to be implemented in the quantities and within the time period allowed under applicable law) or as required by state law an emergency refill will be covered the smallest available package and will not be subject exceed a 30-day supply. In addition to any Copayment or dollar maximums. Select Vaccinations obtained through certain Participating Pharmacies. Benefits for select vaccinations are shown the applicable terms provided in the DEFINITIONS section of the Certificate, the following terms will apply specifically to this provision. Insulin means an insulin analog and an insulin-like medication, regardless of the activation period or whether the solution is mixed before the prescription is dispensed. Insulin-Related Equipment or Supplies means needles, syringes, cartridge systems, prefilled pen systems, glucose meters, continuous glucose monitor supplies, and text strips but does not include insulin pumps. You are responsible for the same Copayment and any pricing differences that may apply to the items dispensed in the same manner as for nonemergency refills of diabetes equipment or supplies. Insulin Drug Program The total amount You may pay for a Covered Drug that contains insulin and is used to treat diabetes will not exceed the amount shown on Your SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS. These vaccinations are available through certain Participating Pharmacies that have contracted with HMO , up to provide this service. To locate one of these Participating Pharmacies in the Pharmacy Vaccine Network in Your area and to determine which vaccinations are covered under this benefit, access the website at xxx.xxxxxx.xxx or contact customer service at the tolla 30-free number on Your identification card. Each Participating Pharmacy included in the Pharmacy Vaccine Network that has contracted with HMO to provide this service may have age, scheduling, or other requirements that will apply, so you are encouraged to contact them in advance. Formulas for the Treatment of Phenylketonuria or Other Heritable Diseases. Dietary formulas necessary for the treatment of phenylketonuria or other heritable diseases are covered to the same extent as any other Covered Drug only on the orders of a Health Care Practitioner. Amino Acid-Based Elemental Formulas. Formulasday supply, regardless of the formula delivery method, used for amount or type of insulin needed to fill the diagnosis Prescription Order. The preferred insulin drugs are identified on Your Drug List and treatment of: • Immunoglobulin E and does not include an insulin drug administered intravenously. Insulin drugs obtained from a non-immunoglobulin E mediated allergies Participating Pharmacy or not identified as a Preferred insulin drug may be subject to multiple food proteins; • Severe food protein-induced enterocolitis syndromes; • Eosinophilic disordersCopayment or dollar maximums, if applicable. Exceptions will not be made for drugs not identified as evidenced by the results of biopsy; and • Disorders affecting the absorptive surface, functional length, and motility of the gastrointestinal tract. A Prescription Order from your Health Care Practitioner is requireda Preferred insulin drug or for an excluded drug.

Covered Drugs. Benefits for Medically Necessary Covered Drugs prescribed to treat You for a chronic, disabling, or life-threatening illness covered by HMO are available if the drug is on the applicable Drug List and has been approved by the United States Food and Drug Administration (FDA) for at least one indication and is recognized by the following for treatment of the indication for which the drug is prescribed: •  a prescription drug reference compendium approved by the Texas Department of Insurance, or •  substantially accepted peer-reviewed medical literature. For a list of Covered Drugs, You can access the website at xxxxx://xxx.xxxxxx.xxx/member/prescription-drug- plan-information/drug-lists or You can also contact customer service at the toll-free number on Your identification card. You are responsible for any Copayments for Covered Drugs shown in THE SCHEDULE OF COPAYMENTS AND Benefit Limits BENEFIT LIMITS and pricing differences that may apply to the Covered Drug dispensed. Injectable Drugs. Injectable drugs approved by the FDA for self-administration are covered. Benefits will not be provided under PHARMACY BENEFITS for any self-administered drugs dispensed by a Physician. Diabetes Supplies for Diabetes Care. Insulin, insulin analogs, insulin pens, insulin syringes, needles, injection devices, glucagon emergency kits, lancets, lancet devices, glucose meter solution, test strips specified for use with a corresponding blood glucose monitor, visual reading strips and urine and blood testing strips, and tablets which test for glucose, ketones, and protein, and prescriptive and nonprescriptive oral agents for controlling blood sugar levels are covered. A separate Copayment will apply to each fill of a prescription purchased on the same day for insulin and insulin syringes. All supplies, including medications and equipment for the control of diabetes will be dispensed as written, unless substitution is approved by Your prescribing Physician or other Health Care Practitioner who issues the written order for the supplies or equipment. Preventive Care. Prescription and over-the-counter drugs which, have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force (“USPSTF”) (to be implemented in the quantities and within the time period allowed under applicable law) or as required by state law will be covered and will not be subject to any Copayment or dollar maximums. Select Vaccinations obtained through certain Participating Pharmacies. Benefits for select vaccinations are shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS. These vaccinations are available through certain Participating Pharmacies that have contracted with HMO to provide this service. To locate one of these Participating Pharmacies in the Pharmacy Vaccine Network in Your area and to determine which vaccinations are covered under this benefit, access the website at xxx.xxxxxx.xxx or contact customer service at the toll-free number on Your identification card. Each Participating Pharmacy included in the Pharmacy Vaccine Network that has contracted with HMO to provide this service may have age, scheduling, or other requirements that will apply, so you are encouraged to contact them in advance. Formulas for the Treatment of Phenylketonuria or Other Heritable Diseases. Dietary formulas necessary for the treatment of phenylketonuria or other heritable diseases are covered to the same extent as any other Covered Drug only on the orders of a Health Care Practitioner. Amino Acid-Based Elemental Formulas. Formulas, regardless of the formula delivery method, used for the diagnosis and treatment of: •  Immunoglobulin E and non-immunoglobulin E mediated allergies to multiple food proteins; •  Severe food protein-induced enterocolitis syndromes; •  Eosinophilic disorders, as evidenced by the results of biopsy; and •  Disorders affecting the absorptive surface, functional length, and motility of the gastrointestinal tract. A Prescription Order from your Health Care Practitioner is required.

Covered Drugs. Benefits for Medically Necessary Covered Drugs prescribed to treat You for a chronic, disabling, or life-threatening illness covered by HMO are available if the drug is on the applicable Drug List and has been approved by the United States Food and Drug Administration (FDA) for at least one indication and is recognized by the following for treatment of the indication for which the drug is prescribed: • a prescription drug reference compendium approved by the Texas Department of Insurance, or • substantially accepted peer-reviewed medical literature. For a list of Covered Drugs, You can access the website at xxxxx://xxx.xxxxxx.xxx/member/prescription-drug- plan-information/drug-lists or You can also contact customer service at the toll-free number on Your identification card. You are responsible for any Copayments for Covered Drugs shown in THE SCHEDULE OF COPAYMENTS AND the Schedule of Copayments and Benefit Limits and pricing differences that may apply to the Covered Drug dispensed. Injectable Drugs. Injectable drugs approved by the FDA for self-administration are covered. Benefits will not be provided under PHARMACY BENEFITS for any self-administered drugs dispensed by a Physician. Diabetes Supplies for Diabetes Care. Insulin, insulin analogs, insulin pens, insulin syringes, needles, injection devices, glucagon emergency kits, lancets, lancet devices, glucose meter solution, test strips specified for use with a corresponding blood glucose monitor, visual reading strips and urine and blood testing strips, and tablets which test for glucose, ketones, and protein, and prescriptive and nonprescriptive oral agents for controlling blood sugar levels are covered. A separate Copayment will apply to each fill of a prescription purchased on the same day for insulin and insulin syringes. All supplies, including medications and equipment for the control of diabetes will be dispensed as written, unless substitution is approved by Your prescribing Physician or other Health Care Practitioner who issues the written order for the supplies or equipment. Preventive Care. Emergency Refills of Insulin or Insulin-Related Equipment and Supplies A pharmacist may exercise their professional judgement in refilling a Prescription and over-the-counter drugs which, have in effect a rating Order for Insulin or Insulin- Related Equipment or Supplies without the authorization of “A” or “B” the prescribing Health Care Practitioner in the current recommendations following situations: • The pharmacist is unable to contact your Health Care Practitioner after reasonable effort; • The pharmacist has documentation showing the patient was previously prescribed insulin or insulin-related equipment or supplies by a Health Care Practitioner; and • The pharmacist accesses the patient to determine whether the emergency refill is appropriate. The quantity of the United States Preventive Services Task Force (“USPSTF”) (to be implemented in the quantities and within the time period allowed under applicable law) or as required by state law an emergency refill will be covered the smallest available package and will not exceed a 30-day supply. In addition to the applicable terms provided in the DEFINITIONS section of the Certificate, the following terms will apply specifically to this provision. Insulin means an insulin analog and an insulin-like medication, regardless of the activation period or whether the solution is mixed before the prescription is dispensed. Insulin-Related Equipment or Supplies means needles, syringes, cartridge systems, prefilled pen systems, glucose meters, continuous glucose monitor supplies, and text strips but does not include insulin pumps. You are responsible for the same Copayment and any pricing differences that may apply to the items dispensed in the same manner as for nonemergency refills of diabetes equipment or supplies. Insulin Drug Program The total amount You may pay for a Covered Drug that contains insulin and is used to treat diabetes will not exceed the amount shown on Your SCHEDULE OF COPAYMENT AND BENEFIT LIMITS, up to a 30-day supply, regardless of the amount or type of insulin needed to fill the Prescription Order. The preferred insulin drugs are identified on Your Drug List and does not include an insulin drug administered intravenously. Insulin drugs obtained from a non-Participating Pharmacy or not identified as a Preferred insulin drug may be subject to any Copayment or dollar maximums, if applicable. Select Vaccinations obtained through certain Participating Pharmacies. Benefits Exceptions will not be made for select vaccinations are shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS. These vaccinations are available through certain Participating Pharmacies that have contracted with HMO to provide this service. To locate one of these Participating Pharmacies in the Pharmacy Vaccine Network in Your area and to determine which vaccinations are covered under this benefit, access the website at xxx.xxxxxx.xxx drugs not identified as a Preferred insulin drug or contact customer service at the toll-free number on Your identification card. Each Participating Pharmacy included in the Pharmacy Vaccine Network that has contracted with HMO to provide this service may have age, scheduling, or other requirements that will apply, so you are encouraged to contact them in advance. Formulas for the Treatment of Phenylketonuria or Other Heritable Diseases. Dietary formulas necessary for the treatment of phenylketonuria or other heritable diseases are covered to the same extent as any other Covered Drug only on the orders of a Health Care Practitioner. Amino Acid-Based Elemental Formulas. Formulas, regardless of the formula delivery method, used for the diagnosis and treatment of: • Immunoglobulin E and non-immunoglobulin E mediated allergies to multiple food proteins; • Severe food protein-induced enterocolitis syndromes; • Eosinophilic disorders, as evidenced by the results of biopsy; and • Disorders affecting the absorptive surface, functional length, and motility of the gastrointestinal tract. A Prescription Order from your Health Care Practitioner is requiredan excluded drug.

Covered Drugs. Benefits for Medically Necessary Covered Drugs prescribed to treat You for a chronic, disabling, or life-life- threatening illness covered by HMO are available if the drug is on the applicable Drug List and has been approved by the United States Food and Drug Administration (FDA) for at least one indication and is recognized by the following for treatment of the indication for which the drug is prescribed: •  a prescription drug reference compendium approved by the Texas Department of Insurance, or •  substantially accepted peer-reviewed medical literature. For a list of Covered Drugs, You can access the website at xxxxx://xxx.xxxxxx.xxx/member/prescription-drug- xxxxx://xxx.xxxxxx.xxx/member/prescription- drug-plan-information/drug-lists or You can also contact customer service at the toll-free number on Your identification card. You are responsible for any Copayments for Covered Drugs shown in THE the SCHEDULE OF COPAYMENTS AND Benefit Limits BENEFIT LIMITS and pricing differences that may apply to the Covered Drug dispensed. Injectable Drugs. Injectable drugs approved by the FDA for self-administration are covered. Benefits will not be provided under PHARMACY BENEFITS for any self-administered drugs dispensed by a Physician. Diabetes Supplies for Diabetes Care. Insulin, insulin analogs, insulin pens, insulin syringes, needles, injection devices, glucagon emergency kits, lancets, lancet devices, glucose meter solution, test strips specified for use with a corresponding blood glucose monitor, visual reading strips and urine and blood testing strips, and tablets which test for glucose, ketones, and protein, and prescriptive and nonprescriptive oral agents for controlling blood sugar levels are covered. A separate Copayment will apply to each fill of a prescription purchased on the same day for insulin and insulin syringes. All supplies, including medications and equipment for the control of diabetes will be dispensed as written, unless substitution is approved by Your prescribing Physician or other Health Care Practitioner who issues the written order for the supplies or equipment. Preventive Care. Prescription and over-the-counter drugs which, which have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force (“USPSTF”) (to be implemented in the quantities and within the time period allowed under applicable law) or as required by state law will be covered and will not be subject to any Copayment or dollar maximums. Select Vaccinations obtained through certain Participating Pharmacies. Benefits for select vaccinations are shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS. These vaccinations are available through certain Participating Pharmacies that have contracted with HMO to provide this service. To locate one of these Participating Pharmacies in the Pharmacy Vaccine Network in Your area and to determine which vaccinations are covered under this benefit, access the website at xxx.xxxxxx.xxx or contact customer service at the toll-free number on Your identification card. Each Participating Pharmacy included in the Pharmacy Vaccine Network that has contracted with HMO to provide this service may have age, scheduling, or other requirements that will apply, so you are encouraged to contact them in advance. Formulas for the Treatment of Phenylketonuria or Other Heritable Diseases. Dietary formulas necessary for the treatment of phenylketonuria or other heritable diseases are covered to the same extent as any other Covered Drug available only on the orders of a Health Care Practitioner. Amino Acid-Based Elemental Formulas. Formulas, regardless of the formula delivery method, used for the diagnosis and treatment of: •  Immunoglobulin E and non-immunoglobulin E mediated allergies to multiple food proteins; •  Severe food protein-induced enterocolitis syndromes; •  Eosinophilic disorders, as evidenced by the results of biopsy; and •  Disorders affecting the absorptive surface, functional length, and motility of the gastrointestinal tract. A Prescription Order from your Your Health Care Practitioner is required.

Covered Drugs. Benefits for Medically Necessary Covered Drugs covered drugs prescribed to treat You for a chronic, disabling, or life-life- threatening illness covered by HMO are available if the drug is on the applicable Drug List and has been approved by the United States Food and Drug Administration (FDA) for at least one indication and is recognized by the following for treatment of the indication for which the drug is prescribed: • a prescription drug reference compendium approved by the Texas Department of Insurance, or • substantially accepted peer-reviewed medical literature. For a list As new drugs are approved by the Food and Drug Administration (FDA), such drugs, unless the intended use is specifically excluded by HMO, may be eligible for benefits if included on the applicable Drug List. Some equivalent drugs are manufactured under multiple brand names. In such cases, HMO may limit benefits to only one of Covered Drugs, You can access the website at xxxxx://xxx.xxxxxx.xxx/member/prescription-drug- plan-information/drug-lists or You can also contact customer service at the toll-free number on Your identification cardbrand equivalents available. You are responsible for any Copayments for Covered Drugs covered drugs shown in THE SCHEDULE OF COPAYMENTS AND the Schedule of Copayments and Benefit Limits and pricing differences that may apply to the Covered Drug covered drug dispensed. Injectable Drugs. Injectable drugs approved by the FDA for self-administration are covered. Benefits Injectable drugs include, but are not limited to, insulin and Imitrex. The day supply of disposable syringes and needles You will not be provided under PHARMACY BENEFITS need for any self-administered injections will be limited on each occasion dispensed to amounts appropriate to the dosage amounts of covered injectable drugs dispensed by actually prescribed and dispensed, but cannot exceed 100 syringes and needles per Prescription Order in a Physician30-day period. Diabetes Supplies for Diabetes Care. Insulin, insulin analogs, insulin pens, insulin syringes, needles, injection devices, glucagon emergency kits, lancets, lancet devices, glucose meter solution, test strips specified for use with a corresponding blood glucose monitor, visual reading strips and urine and blood testing strips, and tablets which test for glucose, ketones, and protein, and prescriptive and nonprescriptive oral agents for controlling blood sugar levels are covered. A separate Copayment will apply to each fill of a prescription purchased on the same day for insulin and insulin syringes. All supplies, including medications and equipment for the control of diabetes will be dispensed as written, unless substitution is approved by Your prescribing Physician or other Health Care Practitioner who issues the written order for the supplies or equipment. Preventive Care. Prescription and over-the-counter drugs which, have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force (“USPSTF”) (to be implemented in the quantities and within the time period allowed under applicable law) or as required by state law will be covered and will not be subject to any Copayment or dollar maximums. Select Vaccinations obtained through certain Participating Pharmacies. Benefits for select vaccinations are shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS. These vaccinations are available through certain Participating Pharmacies that have contracted with HMO to provide this service. To locate one of these Participating Pharmacies in the Pharmacy Vaccine Network in Your area and to determine which vaccinations are covered under this benefit, access the website at xxx.xxxxxx.xxx or contact customer service at the toll-free number on Your identification card. Each Participating Pharmacy included in the Pharmacy Vaccine Network that has contracted with HMO to provide this service may have age, scheduling, or other requirements that will apply, so you are encouraged to contact them in advance. Formulas for the Treatment of Phenylketonuria or Other Heritable Diseases. Dietary formulas necessary for the treatment of phenylketonuria or other heritable diseases are covered to the same extent as any other Covered Drug only on the orders of a Health Care Practitioner. Amino Acid-Based Elemental Formulas. Formulas, regardless of the formula delivery method, used for the diagnosis and treatment of: • Immunoglobulin E and non-immunoglobulin E mediated allergies to multiple food proteins; • Severe food protein-induced enterocolitis syndromes; • Eosinophilic disorders, as evidenced by the results of biopsy; and • Disorders affecting the absorptive surface, functional length, and motility of the gastrointestinal tract. A Prescription Order from your Health Care Practitioner is required.

Covered Drugs. Benefits for Medically Necessary Covered Drugs prescribed to treat You for a chronic, disabling, or life-life- threatening illness covered by HMO are available if the drug is on the applicable Drug List and has been approved by the United States Food and Drug Administration (FDA) for at least one indication and is recognized by the following for treatment of the indication for which the drug is prescribed: • a prescription drug reference compendium approved by the Texas Department of Insurance, or • substantially accepted peer-reviewed medical literature. For a list of Covered Drugs, You can access the website at xxxxx://xxx.xxxxxx.xxx/member/prescription-drug- xxxxx://xxx.xxxxxx.xxx/member/prescription- drug-plan-information/drug-lists or You can also contact customer service at the toll-free number on Your identification card. You are responsible for any Copayments for Covered Drugs shown in THE SCHEDULE OF COPAYMENTS AND the Schedule of Copayments and Benefit Limits and pricing differences that may apply to the Covered Drug dispensed. Injectable Drugs. Injectable drugs approved by the FDA for self-administration are covered. Benefits will not be provided under PHARMACY BENEFITS for any self-administered drugs dispensed by a Physician. Diabetes Supplies for Diabetes Care. Insulin, insulin analogs, insulin pens, insulin syringes, needles, injection devices, glucagon emergency kits, lancets, lancet devices, glucose meter solution, test strips specified for use with a corresponding blood glucose monitor, visual reading strips and urine and blood testing strips, and tablets which test for glucose, ketones, and protein, and prescriptive and nonprescriptive oral agents for controlling blood sugar levels are covered. A separate Copayment will apply to each fill of a prescription purchased on the same day for insulin and insulin syringes. All supplies, including medications and equipment for the control of diabetes will be dispensed as written, unless substitution is approved by Your prescribing Physician or other Health Care Practitioner who issues the written order for the supplies or equipment. Preventive Care. Prescription and over-the-counter drugs which, have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force (“USPSTF”) (to be implemented in the quantities and within the time period allowed under applicable law) or as required by state law will be covered and will not be subject to any Copayment or dollar maximums. Select Vaccinations obtained through certain Participating Pharmacies. Benefits for select vaccinations are shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS. These vaccinations are available through certain Participating Pharmacies that have contracted with HMO to provide this service. To locate one of these Participating Pharmacies in the Pharmacy Vaccine Network in Your area and to determine which vaccinations are covered under this benefit, access the website at xxx.xxxxxx.xxx or contact customer service at the toll-free number on Your identification card. Each Participating Pharmacy included in the Pharmacy Vaccine Network that has contracted with HMO to provide this service may have age, scheduling, or other requirements that will apply, so you are encouraged to contact them in advance. Formulas for the Treatment of Phenylketonuria or Other Heritable Diseases. Dietary formulas necessary for the treatment of phenylketonuria or other heritable diseases are covered to the same extent as any other Covered Drug only on the orders of a Health Care Practitioner. Amino Acid-Based Elemental Formulas. Formulas, regardless of the formula delivery method, used for the diagnosis and treatment of: • Immunoglobulin E and non-immunoglobulin E mediated allergies to multiple food proteins; • Severe food protein-induced enterocolitis syndromes; • Eosinophilic disorders, as evidenced by the results of biopsy; and • Disorders affecting the absorptive surface, functional length, and motility of the gastrointestinal tract. A Prescription Order from your Health Care Practitioner is required.

Covered Drugs. Benefits for Medically Necessary Covered Drugs prescribed to treat You for a chronic, disabling, or life-threatening life‐threatening illness covered by HMO are available if the drug is on the applicable Drug List and has been approved by the United States Food and Drug Administration (FDA) for at least one indication and is recognized by the following for treatment of the indication for which the drug is prescribed: • a prescription drug reference compendium approved by the Texas Department of Insurance, or • substantially accepted peer-reviewed peer‐reviewed medical literature. For a list of Covered DrugsAs new drugs are approved by the Food and Drug Administration (FDA), You can access such drugs, unless the website at xxxxx://xxx.xxxxxx.xxx/member/prescription-drug- plan-information/drug-lists or You can also contact customer service at the toll-free number on Your identification cardintended use is specifically excluded by HMO, may be eligible for benefits. You are responsible for any Copayments for Covered Drugs are shown in THE SCHEDULE OF COPAYMENTS AND the Schedule of Copayments and Benefit Limits and pricing differences that may apply to the Covered Drug dispensedLimits. Injectable Drugs. Injectable drugs approved by the FDA for self-administration self‐administration are covered. Benefits will not be provided under PHARMACY BENEFITS for any self-administered self‐administered drugs dispensed by a Physician. Diabetes Supplies for Diabetes Care. Insulin, insulin analogs, insulin pens, insulin syringes, needles, injection devices, glucagon emergency kits, lancets, lancet devices, glucose meter solution, test strips specified for use with a corresponding blood glucose monitor, visual reading strips and urine and blood testing strips, and tablets which test for glucose, ketones, and protein, and prescriptive and nonprescriptive oral agents for controlling blood sugar levels are covered. A separate Copayment will apply to each fill of a prescription purchased on the same day for insulin and insulin syringes. All supplies, including medications and equipment for the control of diabetes diabetes, will be dispensed as written, written unless substitution is approved by Your prescribing Physician or other Health Care Practitioner who issues the written order for the supplies or equipment. Preventive Care. Prescription and over-the-counter drugs which, have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force (“USPSTF”) (to be implemented in the quantities and within the time period allowed under applicable law) or as required by state law will be covered and will not be subject to any Copayment or dollar maximums. Select Vaccinations obtained through certain Participating Pharmacies. Benefits for select vaccinations are shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS. These vaccinations are available through certain Participating Pharmacies that have contracted with HMO to provide this service. To locate one of these Participating Pharmacies in the Pharmacy Vaccine Network in Your area and to determine which vaccinations are covered under this benefit, access the website at xxx.xxxxxx.xxx or contact customer service at the toll-free number on Your identification card. Each Participating Pharmacy included in the Pharmacy Vaccine Network that has contracted with HMO to provide this service may have age, scheduling, or other requirements that will apply, so you are encouraged to contact them in advance. Formulas for the Treatment of Phenylketonuria or Other Heritable Diseases. Dietary formulas necessary for the treatment of phenylketonuria or other heritable diseases are covered to the same extent as any other Covered Drug available only on the orders of a Health Care Practitioner. Amino Acid-Based Acid‐Based Elemental Formulas. Formulas, regardless of the formula delivery method, used for the diagnosis and treatment of: • Immunoglobulin E and non-immunoglobulin non‐immunoglobulin E mediated allergies to multiple food proteins; • Severe food protein-induced protein‐induced enterocolitis syndromes; • Eosinophilic disorders, as evidenced by the results of biopsy; and • Disorders affecting the absorptive surface, functional length, and motility of the gastrointestinal tract. A Prescription Order from your Your Health Care Practitioner is required. Orally Administered Anticancer Medication. Benefits are available for Medically Necessary orally administered anticancer medication that is used to kill or slow the growth of cancerous cells. Copayments will not apply to certain orally administered anticancer medication. To determine if a specific drug is included in this benefit contact customer service at the toll‐free number on Your identification card. Selecting a Pharmacy When You need a Prescription Order filled, You should use a Participating Pharmacy. Each prescription or refill is subject to the Copayment shown in the Schedule of Copayments and Benefit Limits.