Common use of Preventive Drugs Clause in Contracts

Preventive Drugs. When purchased at any pharmacy: Must be prescribed by a physician. See Prescription Drug section for details. $0 Not Covered Nicotine Replacement Therapy (NRT) and Smoking Cessation Prescription Drugs When purchased at any pharmacy: Must be prescribed by a physician. See Prescription Drug section for details. Tier 1 Preventive: $0 Tier 1 Non-preventive: $10 Not Covered Tier 2 Preventive: $0 Tier 2 Non-preventive: $30 Not Covered Tier 3: $50 - After deductible Not Covered Tier 4: $75 - After deductible Not Covered Tier 5: NRT and Smoking Cessation drugs are only placed in Tier 1, Tier 2, Tier 3, or Tier 4. See above. Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Prescription Drugs Administered bya Provider (other than a Pharmacy). See the Summary of Medical Benefits. See the Summary of Medical Benefits.

Preventive Drugs. When purchased at any pharmacy: Must be prescribed by a physician. See Prescription Drug section for details. $0 Not Covered Nicotine Replacement Therapy (NRT) and Smoking Cessation Prescription Drugs When purchased at any pharmacy: Must be prescribed by a physician. See Prescription Drug section for details. Tier 1 Preventive: $0 Tier 1 Non-preventive: $10 7 Not Covered Tier 2 Preventive: $0 Tier 2 Non-preventive: $30 35 Not Covered Tier 3: $50 - After deductible Not Covered Tier 4: $75 - After deductible Not Covered Tier 5: NRT and Smoking Cessation drugs are only placed in Tier 1, Tier 2, Tier 3, or Tier 4. See above. Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Prescription Drugs Administered bya Provider (other than a Pharmacy). See the Summary of Medical Benefits. See the Summary of Medical Benefits.

Preventive Drugs. When purchased at any pharmacy: Must be prescribed by a physician. See Prescription Drug section for details. $0 0% Not Covered Nicotine Replacement NicotineReplacement Therapy (NRT) and Smoking Cessation Prescription Drugs When purchased at any pharmacy: Must be prescribed by a physician. See Prescription Drug section for details. When a generic brand (Tier 1 Preventive: $0 1) is not available, a preferred brand (Tier 1 Non-preventive: $10 2) will be covered at the Tier level. Tier 1:0% Not Covered Tier 2 Preventive: $0 Tier 2 Non-preventive: $30 2:20%- Afterdeductible Not Covered Tier 3: $50 - After deductible 3:20%- Afterdeductible Not Covered Tier 4: $75 - After deductible Not Covered Tier 5Tier4 and Tier5: NRT and Smoking Cessation drugs are only placed in Tier 1, Tier 2, Tier 3, or Tier 4Tier3. See above. Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Prescription Drugs Administered bya by a Provider (other than a Pharmacy). See the Summary of Medical Benefits. See the Summary of Medical Medic Benefits.

Preventive Drugs. When purchased at any pharmacy: Must be prescribed by a physician. See Prescription Drug section for details. $0 Not Covered Nicotine Replacement Therapy (NRT) and Smoking Cessation Prescription Drugs When purchased at any pharmacy: Must be prescribed by a physician. See Prescription Drug section for details. Tier 1 Preventive: $0 Tier 1 Non-preventive: $10 Not Covered Tier 2 Preventive: $0 Tier 2 Non-preventive: $30 25 Not Covered Tier 3: $50 - After deductible Not Covered Tier 4: $75 - After deductible Not Covered Tier 5: NRT and Smoking Cessation drugs are only placed in Tier 1, Tier 2, Tier 3, or Tier 4. See above. Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Prescription Drugs Administered bya Provider (other than a Pharmacy). See the Summary of Medical Benefits. See the Summary of Medical Benefits.

Preventive Drugs. When purchased at any pharmacy: Must be prescribed by a physician. See Prescription Drug section for details. $0 Not Covered Nicotine Replacement Therapy (NRT) and Smoking Cessation Prescription Drugs When purchased at any pharmacy: Must be prescribed by a physician. See Prescription Drug section for details. Tier 1 Preventive: $0 Tier 1 Non-preventive: $10 - After deductible Not Covered Tier 2 Preventive: $0 Tier 2 Non-preventive: $30 35 - After deductible Not Covered Tier 3: $50 70 - After deductible Not Covered Tier 4: $75 - After deductible Not Covered 4 and Tier 5: NRT and Smoking Cessation drugs are only placed in Tier 1, Tier 2, or Tier 3, or Tier 4. See above. Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Prescription Drugs Administered bya by a Provider (other than a Pharmacy). See the Summary of Medical Benefits. See the Summary of Medical Benefits.

Preventive Drugs. When purchased at any pharmacy: Must be prescribed by a physician. See physiciaSne.e Prescription Drug section for details. $0 Not Covered Nicotine Replacement Therapy (NRT) and Smoking Cessation Prescription Drugs When purchased at any pharmacy: Must be prescribed by a physician. See Prescription Drug section for details. When a generic brand (Tier 1 Preventive1) is not available, a preferred brand (Tier 2) will be covered at the Tier level. Tier 1: $0 Tier 1 Non-preventive: $10 Not Covered Tier 2 Preventive: $0 Tier 2 Non-preventive2: $30 Not Covered Tier 3: $50 - After deductible Not Covered Tier 4: $75 - After deductible Not Covered Tier 5: NRT and Smoking Cessation drugs Cessationdrugs are only placed in Tier 1, Tier 2, Tier 3, or Tier 4. See above. Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Prescription Drugs Administered bya by a Provider (other than a Pharmacy). See the Summary of Medical Benefits. See the Summary of Medical Medic Benefits.