Common use of Outpatient Prescription Drugs Clause in Contracts

Outpatient Prescription Drugs. If you require certain Pharmaceutical Products, including specialty Pharmaceutical Products, we may direct you to a Designated Dispensing Entity. Such Dispensing Entities may include an outpatient pharmacy, specialty pharmacy, Home Health Agency provider, Hospital-affiliated pharmacy or hemophilia treatment center contracted pharmacy. If you/your provider are directed to a Designated Dispensing Entity and you/your provider choose not to get your Pharmaceutical Product from a Designated Dispensing Entity, Benefits are not available for that Pharmaceutical Product, unless the provider or its intermediary agrees in writing to accept reimbursement, including copayment, at the same rate as a Designated Dispensing Entity. Certain Pharmaceutical Products are subject to step therapy requirements. This means that in order to receive Benefits for such Pharmaceutical Products, you must use a different Pharmaceutical Product and/or prescription drug product first. You may find out whether a particular Pharmaceutical Product is subject to step therapy requirements by contacting us at ▇▇▇.▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇ or the telephone number on your ID card. A step therapy requirement may not be imposed if: • The step therapy drug has not been approved by the U.S. Food and Drug Administration (FDA) for the medical condition being treated; or • The prescribing provider provides supporting medical information to us that a Prescription Drug Product: ▪ Was ordered by a prescribing provider for the Covered Person within the past 180 days; and ▪ Based on the professional judgment of the prescribing provider, was effective in treating the Covered Person’s medical condition. • The prescription drug has been approved by the FDA and: ▪ Is being used to treat the Covered Person’s stage four advanced metastatic cancer; and ▪ Use of the prescription drug is consistent with the FDA-approved indication or the National Comprehensive Cancer Network Drugs & Biologics Compendium indication for the treatment of stage four advanced metastatic cancer; and ▪ Is supported by peer-reviewed medical literature. We will have certain programs in which you receive an enhanced Benefit based on your actions such as adherence/compliance to medication or treatment regimens and/or participation in health management programs. You can access information on these programs by contacting us at ▇▇▇.▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇ or the telephone number on your ID card.

Outpatient Prescription Drugs. If you Introduction/Prior We provide Benefits for drugs and medicines obtained at a participating Authorization: pharmacy that require certain Pharmaceutical Products, including specialty Pharmaceutical Products, we may direct you to a Designated Dispensing Entity. Such Dispensing Entities may include an outpatient pharmacy, specialty pharmacy, Home Health Agency provider, Hospital-affiliated pharmacy or hemophilia treatment center contracted pharmacy. If you/your provider are directed to a Designated Dispensing Entity and you/your provider choose not to get your Pharmaceutical Product from a Designated Dispensing Entity, Benefits are not available for that Pharmaceutical Product, unless the provider or its intermediary agrees in writing to accept reimbursement, including copayment, at the same rate as a Designated Dispensing EntityPhysician’s prescription. Certain Pharmaceutical Products medications or classes of medications may require Prior Authorization. To receive Prior Authorization, Your Physician will need to submit to Us a statement of Medical Necessity. Certain medications are subject to step therapy requirements. This means utilization programs that in order require You to receive Benefits for such Pharmaceutical Products, you must try to use a different Pharmaceutical Product and/or prescription drug product firsttherapeutic alternative before another medication will be considered a Covered Service. You Your Physician may find out whether submit to Us a particular Pharmaceutical Product statement of Medical Necessity if the utilization program is subject to step therapy requirements by contacting us at ▇▇▇.▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇ or the telephone number on your ID card. A step therapy requirement may not be imposed if: • The step therapy drug has not been approved by the U.S. Food and Drug Administration (FDA) appropriate for the medical condition being treated; or • The prescribing provider provides supporting medical information to us that a Prescription Drug Product: ▪ Was ordered by a prescribing provider for the Covered Person within the past 180 days; and ▪ Based on the professional judgment of the prescribing provider, was effective in treating the Covered Person’s Your medical condition. • The For participating providers, You must always pay the lower of either: (a) Your applicable Prescription Drug Copayment, specified in the Benefit Schedule; or (b) the participating pharmacy’s Usual and Customary Charge if the Usual and Customary Charge is less than Your Copayment. For purposes of this paragraph, Usual and Customary Charge means the amount that the participating pharmacy would have charged You if You were a cash paying customer. Such amount includes all applicable discounts, including, without limitation, senior citizen’s discounts, coupon discounts, non-insurance discounts, or other special discounts offered to attract customers. Drug Rebates and We contract with a pharmacy benefit manager (“PBM”) for certain Credits: prescription drug has been approved rebate administration services. Under the agreement, PBM obtains rebates from drug manufacturers based on the utilization of certain branded prescription products by Covered Persons. As partial consideration for these services, pharmaceutical manufacturers pay administrative fees to PBM and PBM retains the FDA andbenefit of the funds prior to disbursement. Administrative fees retained by PBM in connection with its rebate program do not exceed the greater of (i) 4.58% of the Average Wholesale Price, or (ii) 5.5% of the wholesale acquisition cost of the products. PBM may also receive other service fees from manufacturers as compensation for various services unrelated to rebates or rebate-associated administrative fees. We receive rebates from the PBM and may from time to time receive financial credits, and/or other amounts (collectively “Financial Credits”) from network pharmacies, drug manufacturers, or the PBM. We retain sole and exclusive right to all Financial Credits and may use such Financial Credits in Our sole and absolute discretion (including, for example, to help stabilize overall rates and to offset expenses). Without limitation to the foregoing, the following rules apply to the Financial Credits: ▪ Is being used (a) You have no right to treat receive, claim or possess any beneficial interest in any Financial Credits; (b) Applicable drug benefit Copayment and/or maximum allowable benefits (including without limitation Calendar Year Maximum and Lifetime Maximum benefits) are in no way adjusted or otherwise affected as a result of any Financial Credits; (c) Any Deductible and/or Coinsurance that You must pay for prescription drugs is based upon the Covered Person’s stage four advanced metastatic cancerAllowable Charge at the pharmacy and does not change as a result of any Financial Credits; and ▪ Use (d) Amounts paid to pharmacies or any prices charged at pharmacies are in no way adjusted or otherwise affected as a result of any Financial Credits. Covered Drugs: Covered Services are limited to: a. Legend drugs that, by federal or state law, can only be dispensed upon written prescription from an authorized prescriber b. Compound medications that contain at least one legend drug in a therapeutic amount c. Off-label use of prescription drugs when treatment of the prescription drug indication is consistent with recognized in one of the FDA-approved indication standard reference compendia or the National Comprehensive Cancer Network Drugs & Biologics Compendium indication for the treatment of stage four advanced metastatic cancer; and ▪ Is supported by in substantially accepted peer-reviewed medical literature. We will have certain programs in which you receive an enhanced Benefit based on your actions such Your Physician must submit documentation supporting the proposed off- label use or uses if requested by Us For this specific Benefit, the following terms are defined as adherence/compliance to medication or treatment regimens and/or participation in health management programs. You can access information on these programs by contacting us at ▇▇▇.▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇ or the telephone number on your ID card.follows: