Common use of Mail Order Program Clause in Contracts

Mail Order Program. If You elect to use the mail- order service, You must mail Your Prescription Order to the address provided on the mail- order prescription form and send in Your payment for each prescription filled or refilled. Each prescription or refill is subject to the Copayment shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS and any applicable pricing differences, payable by Member directly to the mail- order Pharmacy. Some drugs may not be available through the mail- order program. If You have any questions about this mail- order program, need assistance in determining the amount of Your payment, or need to obtain the mail- order prescription claim form, You may access the website at xxx.xxxxxx.xxx/xxxxxx or contact customer service at the toll- free number on Your identification card. Mail the completed form, Your Prescription Order(s) and payment to the address indicated on the form. Prescription Drugs Purchased Outside of the Service Area. HMO will reimburse You for the Allowable Amount of the prescription drugs less the Out- of- Area Drug Copayment shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS, for covered prescription drugs which You purchase outside of the Service Area. You must submit a completed claim form to HMO, including Your name, the prescribing authorized Health Care Practitioner’s name, the date of purchase, NDC of the drug, and itemized receipts indicating the total cost of the prescription within ninety (90) days of the date of purchase to qualify for reimbursement under the PHARMACY BENEFITS. You may access the website at xxx.xxxxxx.xxx/xxxxxx to obtain a prescription drug claim form. Your Cost

Mail Order Program. If You elect to use the mail- mail-order service, You must mail Your Prescription Order to the address provided on the mail- mail-order prescription form and send in Your payment for each prescription filled or refilled. Each prescription or refill is subject to the Copayment shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS and any applicable pricing differences, payable by Member directly to the mail- mail order Pharmacy. Some drugs may not be available through the mail- mail-order program. If You have any questions about this mail- mail-order program, need assistance in determining the amount of Your payment, or need to obtain the mail- mail-order prescription claim form, You may access the website at xxx.xxxxxx.xxx/xxxxxx xxx.xxxxxx.xxx or contact customer service at the toll- toll-free number on Your identification card. Mail the completed form, Your Prescription Order(s) and payment to the address indicated on the form. Specialty Pharmacy Program. The Specialty Drug delivery service integrates Specialty Drug benefits with the Member’s overall medical and prescription drug benefits. This program provides delivery of medications directly from the Specialty Pharmacy Provider to Your Health Care Practitioner, administration location or to the Member that is undergoing treatment for a complex Medical Condition. The HMO Specialty Pharmacy Program delivery service offers:  Coordination of coverage between You, Your Health Care Practitioner and HMO,  Educational materials about the patient’s particular condition and information about managing potential medication side effects,  Syringes, sharps containers, alcohol swabs and other supplies with every shipment for FDA approved self- injectable medications, and  Access to a pharmacist for urgent medication issues 24 hours a day, 7 days a week, 365 days each year. The Drug List which includes these Specialty Drugs is available by accessing the website at xxxxx://xxx.xxxxxx.xxx/member/prescription-drug-plan-information/drug-lists or by contacting customer service at the toll-free number on Your identification card. Your cost will be the applicable Copayment shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS as well as any applicable pricing differences. Prescription Drugs Purchased Outside of the Service Area. HMO will reimburse You for the Allowable Amount of the prescription drugs less the Out- of- Out-of-Area Drug Copayment shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS, for covered prescription drugs which You purchase outside of the Service Area. You must submit a completed claim form to HMO, including Your name, the prescribing authorized Health Care Practitioner’s name, the date of purchase, NDC of the drug, and itemized receipts indicating the total cost of the prescription within ninety (90) days of the date of purchase to qualify for reimbursement under the PHARMACY BENEFITS. You may access the website at xxx.xxxxxx.xxx/xxxxxx xxx.xxxxxx.xxx/xxxxxx/xxxxxxx to obtain a prescription drug claim form. Your Cost

Mail Order Program. If You elect to use the mail- mail-order service, You must mail Your Prescription Order to the address provided on the mail- mail-order prescription form and send in Your payment for each prescription filled or refilled. Each prescription or refill is subject to the Copayment shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS and any applicable pricing differences, payable by Member directly to the mail- mail order Pharmacy. Some drugs may not be available through the mail- mail-order program. If You have any questions about this mail- mail-order program, need assistance in determining the amount of Your payment, or need to obtain the mail- mail-order prescription claim form, You may access the website at xxx.xxxxxx.xxx/xxxxxx xxx.xxxxxx.xxx or contact customer service at the toll- toll-free number on Your identification card. Mail the completed form, Your Prescription Order(s) and payment to the address indicated on the form. Specialty Pharmacy Program. The Specialty Drug delivery service integrates Specialty Drug benefits with the Member’s overall medical and prescription drug benefits. This program provides delivery of medications directly from the Specialty Pharmacy Provider to Your Health Care Practitioner, administration location or to the Member that is undergoing treatment for a complex Medical Condition. The HMO Specialty Pharmacy Program delivery service offers: • coordination of coverage between You, Your Health Care Practitioner and HMO; • educational materials about the patient’s particular condition and information about managing potential medication side effects; • syringes, sharps containers, alcohol swabs and other supplies with every shipment for FDA approved self- injectable medications; and • access to a pharmacist for urgent medication issues 24 hours a day, 7 days a week, 365 days each year. The Drug List which includes these Specialty Drugs is available by accessing the website at xxxxx://xxx.xxxxxx.xxx/member/prescription-drug-plan-information/drug-lists or by contacting customer service at the toll-free number on Your identification card. Your cost will be the applicable Copayment shown in the Schedule of Copayments and Benefit Limits as well as any applicable pricing differences. Prescription Drugs Purchased Outside of the Service Area. HMO will reimburse You for the Allowable Amount of the prescription drugs less the Out- of- Out-of-Area Drug Copayment shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS, for covered prescription drugs which You purchase outside of the Service Area. You must submit a completed claim form to HMO, including Your name, the prescribing authorized Health Care Practitioner’s name, the date of purchase, NDC of the drug, and itemized receipts indicating the total cost of the prescription within ninety (90) days of the date of purchase to qualify for reimbursement under the PHARMACY BENEFITS. You may access the website at xxx.xxxxxx.xxx/xxxxxx xxx.xxxxxx.xxx/xxxxxx/xx_xxxxx to obtain a prescription drug claim form. Your Cost

Mail Order Program. If You elect to use the mail- mail-order service, You must mail Your Prescription Order to the address provided on the mail- mail-order prescription form and send in Your payment for each prescription filled or refilled. Each prescription or refill is subject to the Copayment shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS and any applicable pricing differences, payable by Member directly to the mail- mail order Pharmacy. Some drugs may not be available through the mail- mail-order program. If You have any questions about this mail- mail-order program, need assistance in determining the amount of Your payment, or need to obtain the mail- mail-order prescription claim form, You may access the website at xxx.xxxxxx.xxx/xxxxxx xxx.xxxxxx.xxx or contact customer service at the toll- toll-free number on Your identification card. Mail the completed form, Your Prescription Order(s) and payment to the address indicated on the form. Specialty Pharmacy Program. The Specialty Drug delivery service integrates Specialty Drug benefits with the Member’s overall medical and prescription drug benefits. This program provides delivery of medications directly from the Specialty Pharmacy Provider to Your Health Care Practitioner, administration location or to the Member that is undergoing treatment for a complex Medical Condition. The HMO Specialty Pharmacy Program delivery service offers: • coordination of coverage between You, Your Health Care Practitioner and HMO; • educational materials about the patient’s particular condition and information about managing potential medication side effects; • syringes, sharps containers, alcohol swabs and other supplies with every shipment for FDA approved self- injectable medications; and • access to a pharmacist for urgent medication issues 24 hours a day, 7 days a week, 365 days each year. The Drug List which includes these Specialty Drugs is available by accessing the website at xxx.xxxxxx.xxx/xxxxxx/xxxxxxxxxxxx-xxxx-xxxx-xxxxxxxxxxx/xxxx-xxxxx or by contacting customer service at the toll-free number on Your identification card. Your cost will be the applicable Copayment shown in the Schedule of Copayments and Benefit Limits as well as any applicable pricing differences. Prescription Drugs Purchased Outside of the Service Area. HMO will reimburse You for the Allowable Amount of the prescription drugs less the Out- of- Out-of-Area Drug Copayment shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS, for covered prescription drugs which You purchase outside of the Service Area. You must submit a completed claim form to HMO, including Your name, the prescribing authorized Health Care Practitioner’s name, the date of purchase, NDC of the drug, and itemized receipts indicating the total cost of the prescription within ninety (90) days of the date of purchase to qualify for reimbursement under the PHARMACY BENEFITS. You may access the website at xxx.xxxxxx.xxx/xxxxxx xxx.xxxxxx.xxx/xxxxxx/xxxxx/xxxxxxxxxx to obtain a prescription drug claim form. Your Cost

Mail Order Program. If You elect to use the mail- mail-order service, You must mail Your Prescription Order to the address provided on the mail- mail-order prescription form and send in Your payment for each prescription filled or refilled. Each prescription or refill is subject to the Copayment shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS and any applicable pricing differences, payable by Member directly to the mail- mail order Pharmacy. Some drugs may not be available through the mail- mail-order program. If You have any questions about this mail- mail-order program, need assistance in determining the amount of Your payment, or need to obtain the mail- mail-order prescription claim form, You may access the website at xxx.xxxxxx.xxx/xxxxxx xxx.xxxxxx.xxx or contact customer service at the toll- toll-free number on Your identification card. Mail the completed form, Your Prescription Order(s) and payment to the address indicated on the form. Specialty Pharmacy Program. The Specialty Drug delivery service integrates Specialty Drug benefits with the Member’s overall medical and prescription drug benefits. This program provides delivery of medications directly from the Specialty Pharmacy Provider to Your Health Care Practitioner, administration location or to the Member that is undergoing treatment for a complex Medical Condition. The HMO Specialty Pharmacy Program delivery service offers:  Coordination of coverage between You, Your Health Care Practitioner and HMO,  Educational materials about the patient’s particular condition and information about managing potential medication side effects,  Syringes, sharps containers, alcohol swabs and other supplies with every shipment for FDA approved self-injectable medications, and  Access to a pharmacist for urgent medication issues 24 hours a day, 7 days a week, 365 days each year. The Drug List which includes these Specialty Drugs is available by accessing the website at xxxxx://xxx.xxxxxx.xxx/member/prescription-drug-plan-information/drug-lists or by contacting customer service at the toll-free number on Your identification card. Your cost will be the applicable Copayment shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS as well as any applicable pricing differences. Prescription Drugs Purchased Outside of the Service Area. HMO will reimburse You for the Allowable Amount of the prescription drugs less the Out- of- Out-of-Area Drug Copayment shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS, for covered prescription drugs which You purchase outside of the Service Area. You must submit a completed claim form to HMO, including Your name, the prescribing authorized Health Care Practitioner’s name, the date of purchase, NDC of the drug, and itemized receipts indicating the total cost of the prescription within ninety (90) days of the date of purchase to qualify for reimbursement under the PHARMACY BENEFITS. You may access the website at xxx.xxxxxx.xxx/xxxxxx xxx.xxxxxx.xxx/xxxxxx/xx_xxxxx to obtain a prescription drug claim form. Your Cost

Mail Order Program. If You elect to use the mail- mail-order service, You must mail Your Prescription Order to the address provided on the mail- mail-order prescription form and send in Your payment for each prescription filled or refilled. Each prescription or refill is subject to the Copayment shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS and any applicable pricing differences, payable by Member directly to the mail- mail order Pharmacy. Some drugs may not be available through the mail- mail-order program. If You have any questions about this mail- mail-order program, need assistance in determining the amount of Your payment, or need to obtain the mail- mail-order prescription claim form, You may access the website at xxx.xxxxxx.xxx/xxxxxx xxx.xxxxxx.xxx/xxxxxx/xx_xxxxx or contact customer service at the toll- toll-free number on Your identification card. Mail the completed form, Your Prescription Order(s) and payment to the address indicated on the form. Specialty Pharmacy Program. The Specialty Drug delivery service integrates Specialty Drug benefits with the Member’s overall medical and prescription drug benefits. This program provides delivery of medications directly from the Specialty Pharmacy Provider to Your Health Care Practitioner, administration location or to the Member that is undergoing treatment for a complex Medical Condition. The HMO Specialty Pharmacy Program delivery service offers: • Coordination of coverage between You, Your Health Care Practitioner and HMO, • Educational materials about the patient’s particular condition and information about managing potential medication side effects, • Syringes, sharps containers, alcohol swabs and other supplies with every shipment for FDA approved self-injectable medications, and • Access to a pharmacist for urgent medication issues 24 hours a day, 7 days a week, 365 days each year. The Drug List which includes these Specialty Drugs is available by accessing the website at xxx.xxxxxx.xxx/xxxxxx/xx_xxxxx or by contacting customer service at the toll-free number on Your identification card. Your cost will be the applicable Copayment shown in the Schedule of Copayments and Benefit Limits as well as any applicable pricing differences. Prescription Drugs Purchased Outside of the Service Area. HMO will reimburse You for the Allowable Amount of the prescription drugs less the Out- of- Out-of-Area Drug Copayment shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS, for covered prescription drugs which You purchase outside of the Service Area. You must submit a completed claim form to HMO, including Your name, the prescribing authorized Health Care Practitioner’s name, the date of purchase, NDC of the drug, and itemized receipts indicating the total cost of the prescription within ninety (90) days of the date of purchase to qualify for reimbursement under the PHARMACY BENEFITS. You may access the website at xxx.xxxxxx.xxx/xxxxxx xxx.xxxxxx.xxx/xxxxxx/xx_xxxxx to obtain a prescription drug claim form. Your Cost

Mail Order Program. If You elect to use the mail- order service, You must mail Your Prescription Order to the address provided on the mail- order prescription form and send in Your payment for each prescription filled or refilled. Each prescription or refill is subject to the Copayment shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS and any applicable pricing differences, payable by Member directly to the mail- order Pharmacy. Some drugs may not be available through the mail- order program. If You have any questions about this mail- order program, need assistance in determining the amount of Your payment, or need to obtain the mail- order prescription claim form, You may access the website at xxx.xxxxxx.xxx/xxxxxx or contact customer service at the toll- free number on Your identification card. Mail the completed form, Your Prescription Order(s) and payment to the address indicated on the form. Prescription Drugs Purchased Outside of the Service Area. HMO will reimburse You for the Allowable Amount of the prescription drugs less the Out- of- Area Drug Copayment shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS, for covered prescription drugs which You purchase outside of the Service Area. You must submit a completed claim form to HMO, including Your name, the prescribing authorized Health Care Practitioner’s name, the date of purchase, NDC of the drug, and itemized receipts indicating the total cost of the prescription within ninety (90) days of the date of purchase to qualify for reimbursement under the PHARMACY BENEFITS. You may access the website at xxx.xxxxxx.xxx/xxxxxx to obtain a prescription drug claim form. Your CostSample

Mail Order Program. If You elect to use the mail- order service, You must mail Your Prescription Order to the address provided on the mail- order prescription form and send in Your payment for each prescription filled or refilled. Each prescription or refill is subject to the Copayment shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS and any applicable pricing differences, payable by Member directly to the mail- order Pharmacy. Some drugs may not be available through the mail- order program. If You have any questions about this mail- order program, need assistance in determining the amount of Your payment, or need to obtain the mail- order prescription claim form, You may access the website at xxx.xxxxxx.xxx/xxxxxx xxx.xxxxxx.xxx/xxxxxx/xx_xxxxx.xxxx or contact customer service at the toll- free number on Your identification card. Mail the completed form, Your Prescription Order(sOrders(s) and payment to the address indicated on the form. Sample Prescription Drugs Purchased Outside of the Service Area. HMO will reimburse You for the Allowable Amount of the prescription drugs less the Out- of- Area Drug Copayment shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS, for covered prescription drugs which You purchase outside of the Service Area. You must submit a completed claim form to HMO, including Your name, the prescribing authorized Health Care Practitioner’s name, the date of purchase, NDC of the drug, and itemized receipts indicating the total cost of the prescription within ninety (90) days of the date of purchase to qualify for reimbursement under the PHARMACY BENEFITS. You may access the website at xxx.xxxxxx.xxx/xxxxxx xxx.xxxxxx.xxx/xxxxxx/xx_xxxxx.xxxx to obtain a prescription drug reimbursement claim form. Your Cost

Mail Order Program. If You elect to use the mail- mail-order service, You must mail Your Prescription Order to the address provided on the mail- mail-order prescription form and send in Your payment for each prescription filled or refilled. Each prescription or refill is subject to the Copayment shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS and any applicable pricing differences, payable by Member directly to the mail- mail order Pharmacy. Some drugs may not be available through the mail- mail-order program. If You have any questions about this mail- mail-order program, need assistance in determining the amount of Your payment, or need to obtain the mail- mail-order prescription claim form, You may access the website at xxx.xxxxxx.xxx/xxxxxx xxx.xxxxxx.xxx or contact customer service at the toll- toll-free number on Your identification card. Mail the completed form, Your Prescription Order(s) and payment to the address indicated on the form. Specialty Pharmacy Program. The Specialty Drug delivery service integrates Specialty Drug benefits with the Member’s overall medical and prescription drug benefits. This program provides delivery of medications directly from the Specialty Pharmacy Provider to Your Health Care Practitioner, administration location or to the Member that is undergoing treatment for a complex Medical Condition. The HMO Specialty Pharmacy Program delivery service offers: • Coordination of coverage between You, Your Health Care Practitioner and HMO, • Educational materials about the patient’s particular condition and information about managing potential medication side effects, • Syringes, sharps containers, alcohol swabs and other supplies with every shipment for FDA approved self- injectable medications, and • Access to a pharmacist for urgent medication issues 24 hours a day, 7 days a week, 365 days each year. The Drug List which includes these Specialty Drugs is available by accessing the website at xxxxx://xxx.xxxxxx.xxx/member/prescription-drug-plan-information/drug-lists or by contacting customer service at the toll-free number on Your identification card. Your cost will be the applicable Copayment shown in the Schedule of Copayments and Benefit Limits as well as any applicable pricing differences. Prescription Drugs Purchased Outside of the Service Area. HMO will reimburse You for the Allowable Amount of the prescription drugs less the Out- of- Out-of-Area Drug Copayment shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS, for covered prescription drugs which You purchase outside of the Service Area. You must submit a completed claim form to HMO, including Your name, the prescribing authorized Health Care Practitioner’s name, the date of purchase, NDC of the drug, and itemized receipts indicating the total cost of the prescription within ninety (90) days of the date of purchase to qualify for reimbursement under the PHARMACY BENEFITS. You may access the website at xxx.xxxxxx.xxx/xxxxxx xxx.xxxxxx.xxx/ member/rxdrugs to obtain a prescription drug claim form. Your CostCost How Copayment Amounts Apply. If the Allowable Amount of the drug is less than the Copayment, You pay the lower cost. When that lower cost is more than the amount You would pay if You purchased the drug without using Your HMO pharmacy benefits or any other source of drug benefits or discounts You pay such purchase price. You will pay no more than the applicable Brand Name Drug Copayment if the prescription has no generic equivalent. If You receive a Brand Name Drug when a generic equivalent is available, the Copayment will be the total of the Generic Drug Copayment plus the difference between the cost of the Generic Drug equivalent and the cost of the Brand Name Drug. Exceptions to this may be allowed for certain preventive medications (including prescription contraceptive medications) if Your Health Care Practitioner submits a request to HMO indicating that the Generic Drug would be medically inappropriate, along with supporting documentation. If HMO grants the exception request, any difference between the Allowable Amount for the Brand Name Drug and the Generic Drug equivalent will be waived. 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 Health Care Practitioner 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 Health Care Practitioner 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 Health Care Practitioner 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 use/medication error. This form is available on the FDA website. If the waiver is granted, applicable Copayment Amount will still apply. For additional information, You may access the website at xxx.xxxxxx.xxx or contact customer service at the toll free number on Your identification card. How Member Payment is Determined. Prescription drug products are separated into tiers. Generally, each drug is placed into one of six drug tiers: • Tier 1 - includes mostly Preferred Generic Drugs and may contain some Brand Name Drugs. • Tier 2 - includes mostly Non-Preferred Generic Drugs and may contain some Brand Name Drugs. • Tier 3 - includes mostly Preferred Brand Name Drugs and may contain some Generic Drugs. • Tier 4 - includes mostly Non-Preferred Brand Name Drugs and may contain some Generic Drugs. • Tier 5 - includes mostly Preferred Specialty Drugs and may contain some Generic Drugs. • Tier 6- includes mostly Non-Preferred Specialty Drugs and may contain some Generic Drugs. Copayments for Covered Drugs on each drug tier is shown in the Schedule of Copayments and Benefit Limits. To determine the tier in which a drug is included, access the website at xxxxx://xxx.xxxxxx.xxx/member/prescription-drug-plan-information/drug-lists or contact customer service at the toll-free number on Your identification card. About Your Benefits Covered Drug List. Drugs listed on the Drug List are selected by HMO based upon the recommendations of a committee, which is made up of current and previously practicing physicians and pharmacists from across the country, some of whom are employed by or affiliated with HMO. The committee considers existing drugs approved by the FDA, as well as those newly FDA approved for inclusion on the Drug List. Entire drug classes are also regularly reviewed. Some of the factors committee members evaluate include each drug’s safety, effectiveness, cost and how it compares with drugs currently on the Drug List. Positive changes (e.g., adding drugs to the Drug List, drugs moving to a lower payment tier) occur quarterly after review by the committee. Changes to the Drug List that could have an adverse financial impact to You (e.g., drug exclusion, drug moving to a higher payment tier, or drugs requiring step therapy or prior authorization) occur only annually. However, where there has been a pharmaceutical manufacturer’s recall or other safety concern, changes to the Drug List may occur more frequently. The Drug List and any modifications will be made available to You. By accessing the Blue Cross and Blue Shield website at htpps://xxx.xxxxxx.xxx/xxxxxx/xxxxxxxxxxxx-xxxx-xxxx-xxxxxxxxxxx/xxxx-xxxxx or calling the customer service toll-free number on Your identification card, You will be able to determine the Drug List that applies to You and whether a particular drug is on the Drug List. Changes to the Drug List will be implemented on the next renewal date of the Group Agreement and are subject to the requirements of Texas Insurance Code, 1369.0541.

Mail Order Program. If You elect to use the mail- mail-order service, You must mail Your Prescription Order to the address provided on the mail- mail-order prescription form and send in Your payment for each prescription filled or refilled. Each prescription or refill is subject to the Copayment shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS and any applicable pricing differences, payable by Member directly to the mail- mail order Pharmacy. Some drugs may not be available through the mail- mail-order program. If You have any questions about this mail- mail-order program, need assistance in determining the amount of Your payment, or need to obtain the mail- mail-order prescription claim form, You may access the website at xxx.xxxxxx.xxx/xxxxxx xxx.xxxxxx.xxx or contact customer service at the toll- toll-free number on Your identification card. Mail the completed form, Your Prescription Order(s) and payment to the address indicated on the form. Specialty Pharmacy Program. The Specialty Drug delivery service integrates Specialty Drug benefits with the Member's overall medical and prescription drug benefits. This program provides delivery of medications directly from the Specialty Pharmacy Provider to Your Health Care Practitioner, administration location or to the Member that is undergoing treatment for a complex Medical Condition. The HMO Specialty Pharmacy Program delivery service offers: • Coordination of coverage between You, Your Health Care Practitioner and HMO, • Educational materials about the patient's particular condition and information about managing potential medication side effects, • Syringes, sharps containers, alcohol swabs and other supplies with every shipment for FDA approved self- injectable medications, and • Access to a pharmacist for urgent medication issues 24 hours a day, 7 days a week, 365 days each year. The Drug List which includes these Specialty Drugs is available by accessing the website at xxxxx://xxx.xxxxxx.xxx/member/prescription-drug-plan-information/drug-lists or by contacting customer service at the toll-free number on Your identification card. Your cost will be the applicable Copayment shown in the Schedule of Copayments and Benefit Limits as well as any applicable pricing differences. Prescription Drugs Purchased Outside of the Service Area. HMO will reimburse You for the Allowable Amount of the prescription drugs less the Out- of- Out-of-Area Drug Copayment shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS, for covered prescription drugs which You purchase outside of the Service Area. You must submit a completed claim form to HMO, including Your name, the prescribing authorized Health Care Practitioner’s name, the date of purchase, NDC of the drug, and itemized receipts indicating the total cost of the prescription within ninety (90) days of the date of purchase to qualify for reimbursement under the PHARMACY BENEFITS. You may access the website at xxx.xxxxxx.xxx/xxxxxx xxx.xxxxxx.xxx/xxxxxx/xxxxxxx to obtain a prescription drug claim form. Your CostCost How Copayment Amounts Apply. If the Allowable Amount of the drug is less than the Copayment, You pay the TX-G-H-NCC-COC-20 46 lower cost. When that lower cost is more than the amount You would pay if You purchased the drug without using Your HMO pharmacy benefits or any other source of drug benefits or discounts You pay such purchase price. You will pay no more than the applicable Brand Name Drug Copayment if the prescription has no generic equivalent. If You receive a Brand Name Drug when a generic equivalent is available, the Copayment will be the total of the Generic Drug Copayment plus the difference between the cost of the Generic Drug equivalent and the cost of the Brand Name Drug. Exceptions to this may be allowed for certain preventive medications (including prescription contraceptive medications) if Your Health Care Practitioner submits a request to HMO indicating that the Generic Drug would be medically inappropriate, along with supporting documentation. If HMO grants the exception request, any difference between the Allowable Amount for the Brand Name Drug and the Generic Drug equivalent will be waived. 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 Health Care Practitioner 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 Health Care Practitioner 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 Health Care Practitioner 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 use/medication error. This form is available on the FDA website. If the waiver is granted, applicable Copayment Amount will still apply. For additional information, You may access the website at xxx.xxxxxx.xxx or contact customer service at the toll free number on Your identification card. How Member Payment is Determined. Prescription drug products are separated into tiers. Generally, each drug is placed into one of six drug tiers: • Tier 1 - includes mostly Preferred Generic Drugs and may contain some Brand Name Drugs. • Tier 2 - includes mostly Non-Preferred Generic Drugs and may contain some Brand Name Drugs. • Tier 3 - includes mostly Preferred Brand Name Drugs and may contain some Generic Drugs. • Tier 4 - includes mostly Non-Preferred Brand Name Drugs and may contain some Generic Drugs. • Tier 5 - includes mostly Preferred Specialty Drugs and may contain some Generic Drugs. • Tier 6- includes mostly Non-Preferred Specialty Drugs and may contain some Generic Drugs. Copayments for Covered Drugs on each drug tier is shown in the Schedule of Copayments and Benefit Limits. To determine the tier in which a drug is included, access the website at xxxxx://xxx.xxxxxx.xxx/member/prescription-drug-plan-information/drug-lists or contact customer service at the toll-free number on Your identification card. About Your Benefits Covered Drug List. Drugs listed on the Drug List are selected by HMO based upon the recommendations of a committee, which is made up of current and previously practicing physicians and pharmacists from across the country, some of whom are employed by or affiliated with HMO. The committee considers existing drugs approved by the FDA, as well as those newly FDA approved for inclusion on the Drug List. Entire drug classes are also regularly reviewed. Some of the factors committee members evaluate include each drug's safety, effectiveness, cost and how it compares with drugs currently on the Drug List. Positive changes (e.g., adding drugs to the Drug List, drugs moving to a lower payment tier) occur quarterly after review by the committee. Changes to the Drug List that could have an adverse financial impact to You (e.g., drug exclusion, drug moving to a higher payment tier, or drugs requiring step therapy or prior authorization) occur only annually. However, where there has been a pharmaceutical manufacturer's recall or other safety concern, changes to the Drug List may occur more frequently. The Drug List and any modifications will be made available to You. By accessing the Blue Cross and Blue Shield website at htpps://xxx.xxxxxx.xxx/xxxxxx/xxxxxxxxxxxx-xxxx-xxxx-xxxxxxxxxxx/xxxx-xxxxx or calling the customer service toll-free number on Your identification card, You will be able to determine the Drug List that applies to You and whether a particular drug is on the Drug List. Changes to the Drug List will be implemented on the next renewal date of the Group Agreement and are subject to the requirements of Texas Insurance Code, 1369.0541.

Mail Order Program. If You elect to use the mail- mail-order service, You must mail Your Prescription Order to the address provided on the mail- mail-order prescription form and send in Your payment for each prescription filled or refilled. Each prescription or refill is subject to the Copayment shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS and any applicable pricing differences, payable by Member directly to the mail- mail order Pharmacy. Some drugs may not be available through the mail- mail-order program. If You have any questions about this mail- mail-order program, need assistance in determining the amount of Your payment, or need to obtain the mail- mail-order prescription claim form, You may access the website at xxx.xxxxxx.xxx/xxxxxx xxx.xxxxxx.xxx or contact customer service at the toll- toll-free number on Your identification card. Mail the completed form, Your Prescription Order(s) and payment to the address indicated on the form. Specialty Pharmacy Program. The Specialty Drug delivery service integrates Specialty Drug benefits with the Member’s overall medical and prescription drug benefits. This program provides delivery of medications directly from the Specialty Pharmacy Provider to Your Health Care Practitioner, administration location or to the Member that is undergoing treatment for a complex Medical Condition. The HMO Specialty Pharmacy Program delivery service offers: • Coordination of coverage between You, Your Health Care Practitioner and HMO, • Educational materials about the patient’s particular condition and information about managing potential medication side effects, • Syringes, sharps containers, alcohol swabs and other supplies with every shipment for FDA approved self-injectable medications, and • Access to a pharmacist for urgent medication issues 24 hours a day, 7 days a week, 365 days each year. The Drug List which includes these Specialty Drugs is available by accessing the website at xxxxx://xxx.xxxxxx.xxx/member/prescription-drug-plan-information/drug-lists or by contacting customer service at the toll-free number on Your identification card. Your cost will be the applicable Copayment shown in the Schedule of Copayments and Benefit Limits as well as any applicable pricing differences. Prescription Drugs Purchased Outside of the Service Area. HMO will reimburse You for the Allowable Amount of the prescription drugs less the Out- of- Out-of-Area Drug Copayment shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS, for covered prescription drugs which You purchase outside of the Service Area. You must submit a completed claim form to HMO, including Your name, the prescribing authorized Health Care Practitioner’s name, the date of purchase, NDC of the drug, and itemized receipts indicating the total cost of the prescription within ninety (90) days of the date of purchase to qualify for reimbursement under the PHARMACY BENEFITS. You may access the website at xxx.xxxxxx.xxx/xxxxxx xxx.xxxxxx.xxx/xxxxxx/xx_xxxxx to obtain a prescription drug claim form. Your Cost

Mail Order Program. If You elect to use the mail- order service, You must mail Your Prescription Order to the address provided on the mail- order prescription form and send in Your payment for each prescription filled or refilled. Each prescription or refill is subject to the Copayment shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS and any applicable pricing differences, payable by Member directly to the mail- order Pharmacy. Some drugs may not be available through the mail- order program. If You have any questions about this mail- order program, need assistance in determining the amount of Your payment, or need to obtain the mail- order prescription claim form, You may access the website at xxx.xxxxxx.xxx/xxxxxx or contact customer service at the toll- free number on Your identification card. Mail the completed form, Your Prescription Order(s) and payment to the address indicated on the form. Specialty Pharmacy Program. The Specialty Drug delivery service integrates Specialty Drug benefits with the Member’s overall medical and prescription drug benefits. This program provides delivery of medications directly from the Specialty Pharmacy Provider to Your Health Care Practitioner, administration location or to the Member that is undergoing treatment for a complex Medical Condition. Due to special storage requirements and high cost, Specialty Drugs are not covered unless obtained through the Specialty Pharmacy Provider. The HMO Specialty Pharmacy Provider delivery service offers:  Coordination of coverage between You, Your Health Care Practitioner and HMO,  Educational materials about the patient’s particular condition and information about managing potential medical side effects,  Syringes, sharps, containers, alcohol swabs and other supplies with every shipment for FDA approved self- injectable medications, and  Access to a pharmacist for urgent medication issues 24 hours a day, 7 days a week, 365 days each year. A list identifying these Specialty Drugs is available by accessing the website at xxx.xxxxxx.xxx/xxxxxx or by contacting the customer service at the toll- free number on Your identification card. Your cost will be the appropriate Copayment shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS and any applicable pricing differences. Prescription Drugs Purchased Outside of the Service Area. HMO will reimburse You for the Allowable Amount of the prescription drugs less the Out- of- Area Drug Copayment shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS, for covered prescription drugs which You purchase outside of the Service Area. You must submit a completed claim form to HMO, including Your name, the prescribing authorized Health Care Practitioner’s name, the date of purchase, NDC of the drug, and itemized receipts indicating the total cost of the prescription within ninety (90) days of the date of purchase to qualify for reimbursement under the PHARMACY BENEFITS. You may access the website at xxx.xxxxxx.xxx/xxxxxx to obtain a prescription drug claim form. Your Cost