Common use of Pharmacy Benefits - Prescription Drugs and Diabetic Equipment or Supplies from a Pharmacy Clause in Contracts

Pharmacy Benefits - Prescription Drugs and Diabetic Equipment or Supplies from a Pharmacy. This plan covers prescription drugs listed on our formulary and diabetic equipment or supplies purchased from a pharmacy as a pharmacy benefit. Our formulary includes a tiered copayment structure and indicates if a prescription drug has a quantity limit or requires preauthorization. If a prescription drug is not on our formulary, it is not covered. For specific coverage information or a copy of the most current formulary, please visit our website or call our Customer Service Department. Types of Pharmacies Prescription drugs and diabetic equipment or supplies can be purchased from the following types of pharmacies: • Retail pharmacies. These dispense prescription drugs and diabetic equipment or supplies. • Mail order pharmacies. These dispense maintenance and non-maintenance prescription drugs and diabetic equipment or supplies. • Specialty pharmacies. These dispense specialty prescription drugs, defined as such on our formulary. For information about our network retail, mail order, and specialty pharmacies, visit our website or call our Customer Service Department. The Amount You Pay for Prescription Drugs Our formulary includes a tiered copayment structure, which means the amount you pay for prescription drugs purchased at a pharmacy will vary by tier. See the Summary of Pharmacy Benefits for your copayment structure, benefit limits and the amount you pay. When you buy covered prescription drugs and diabetic equipment and supplies from a retail network pharmacy, you will be responsible for the copayment and deductible (if any) at the time of purchase. You will be responsible for paying the lower of your copayment, the retail cost of the drug, or the pharmacy allowance. Specialty prescription drugs are generally obtained from a specialty pharmacy. If you buy a specialty prescription drug from a retail network pharmacy, you will be responsible for a significantly higher out of pocket expense than if you purchased the specialty drug from a specialty pharmacy. The amount you pay for the following prescription drugs purchased at a pharmacy is not subject to the tiered copayment structure: • Contraceptive methods; • Over-the-counter (OTC) preventive drugs; • Nicotine replacement therapy (NRT) and smoking cessation prescription drugs; • Infertility specialty prescription drugs; and • Covered diabetic equipment or supplies purchased at a network pharmacy. See the Summary of Pharmacy Benefits for benefit limits and the amount you pay. This plan allows for medication synchronization in accordance with R.I. General Law

Pharmacy Benefits - Prescription Drugs and Diabetic Equipment or Supplies from a Pharmacy. This plan covers prescription drugs listed on our formulary and diabetic equipment or supplies purchased from a pharmacy as a pharmacy benefit. Our formulary includes a tiered copayment structure and indicates if a prescription drug has a quantity limit or requires preauthorization. If a prescription drug is not on our formulary, it is not covered. For specific coverage information or a copy of the most current formulary, please visit our website or call our Customer Service Department. Types of Pharmacies Prescription drugs and diabetic equipment or supplies can be purchased from the following types of pharmacies: • Retail pharmacies. These dispense prescription drugs and diabetic equipment or supplies. • Mail order pharmacies. These dispense maintenance and non-maintenance prescription drugs and diabetic equipment or supplies. • Specialty pharmacies. These dispense specialty prescription drugs, defined as such on our formulary. For information about our network retail, mail order, and specialty pharmacies, visit our website or call our Customer Service Department. The Amount You Pay for Prescription Drugs Our formulary includes a tiered copayment structure, which means the amount you pay for prescription drugs purchased at a pharmacy will vary by tier. See the Summary of Pharmacy Benefits for your copayment structure, benefit limits and the amount you pay. When you buy covered prescription drugs and diabetic equipment and supplies from a retail network pharmacy, you will be responsible for the copayment and deductible (if any) at the time of purchase. You will be responsible for paying the lower of your copayment, the retail cost of the drug, or the pharmacy allowance. Specialty prescription drugs are generally obtained from a specialty pharmacy. If you buy a specialty prescription drug from a retail network pharmacy, you will be responsible for a significantly higher out of pocket expense than if you purchased the specialty drug from a specialty pharmacy. The amount you pay for the following prescription drugs purchased at a pharmacy is not subject to the tiered copayment structure: • Contraceptive methodsmethods covered as a preventive care service; • Over-the-counter (OTC) drugs covered as a preventive drugscare service; • Nicotine replacement therapy (NRT) and smoking cessation prescription drugsdrugs covered as a preventive care service; • Infertility specialty prescription drugs; and • Covered diabetic equipment or supplies purchased at a network pharmacy. Not all contraceptive drugs or devices are listed on our formulary or are covered as a preventive care service. If you or your provider decide that you need a different contraceptive drug or device than those listed on our formulary or those covered as a preventive care service, you or your provider may request an exception using our Contraceptive Copayment Waiver form. For more information, please visit our website or call our Customer Service Department. See the Summary of Pharmacy Benefits for benefit limits and the amount you pay. This plan allows for medication synchronization in accordance with R.I. General Law