Common use of Prescription Drugs and Diabetic Equipment and Supplies Clause in Contracts

Prescription Drugs and Diabetic Equipment and Supplies. Prescription drugs and diabetic Equipment and Supplies dispensed at a pharmacy. See Summary of Pharmacy Benefits for prescription drugs purchased at a retail, specialty, or mail order pharmacy. Prescription drugs dispensed and administered by a licensed health care provider (other than a pharmacist), and not purchased from a retail, specialty or mail order pharmacy: Injectable drugs* 0% - After deductible 40% - After deductible Infused drugs* 0% - After deductible 40% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Medications other than injected and infused rugs* Are included in the allowance for the medical service being rendered. Are included in the allowance for the medical service being rendered.

Prescription Drugs and Diabetic Equipment and Supplies. Prescription drugs and diabetic Equipment equipment and Supplies supplies dispensed at a pharmacy. See Summary of Pharmacy Benefits for prescription drugs purchased at a retail, specialty, or mail order pharmacy. Prescription drugs dispensed and administered by a licensed health care provider (other than a pharmacist), and not purchased from a retail, specialty or mail order pharmacy: Injectable drugs* 0% - After deductible 4020% - After deductible Infused drugs* 0% - After deductible 4020% - After deductible Medications other than injected and infused drugs* Are included in the allowance for the medical service being rendered. Are included in the allowance for the medical service being rendered. Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this serviceservice or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay Medications other than injected and infused rugs* Are included in the allowance for the medical service being rendered. Are included in the allowance for the medical service being rendered.Pay

Prescription Drugs and Diabetic Equipment and Supplies. Prescription drugs and diabetic Equipment equipment and Supplies supplies dispensed at a pharmacy. See Summary of Pharmacy Benefits for prescription drugs purchased at a retail, specialty, or mail order pharmacy. Prescription drugs dispensed and administered by a licensed health care provider (other than a pharmacist), and not purchased from a retail, specialty or mail order pharmacy: Injectable drugs* 0% - After deductible 40% - After deductible Not Covered Infused drugs* 0% - After deductible 40% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this serviceservice or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay Medications other than injected and infused rugsdrugs* Are included in the allowance for the medical service being rendered. Are included in the allowance for the medical service being rendered.

Prescription Drugs and Diabetic Equipment and Supplies. Prescription drugs and diabetic Equipment equipment and Supplies supplies dispensed at a pharmacy. See Summary of Pharmacy Benefits for prescription drugs purchased at a retail, specialty, or mail order pharmacy. Prescription drugs dispensed and administered by a licensed health care provider (other than a pharmacist), and not purchased from a retail, specialty or mail order pharmacy: Injectable drugs* 010% - After deductible 40Not Covered Infused drugs* 10% - After deductible Infused drugs* 0% - After deductible 40% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Medications other than injected and infused rugs* Are included in the allowance for the medical service being rendered. Are included in the allowance for the medical service being rendered.Not Covered

Prescription Drugs and Diabetic Equipment and Supplies. Prescription drugs and diabetic Equipment equipment and Supplies supplies dispensed at a pharmacy. See Summary of Pharmacy Benefits for prescription drugs purchased at a retail, specialty, or mail order pharmacy. Prescription drugs dispensed and administered by a licensed health care provider (other than a pharmacist), and not purchased from a retail, specialty or mail order pharmacy: Injectable drugs* 0% - After deductible 40% - After deductible Infused drugs* 0% - After deductible 40% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Medications other than injected and infused rugs* Are included in the allowance for the medical service being rendered. Are included in the allowance for the medical service being rendered.