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(7) Prescriptions are covered as long as they are listed on the prescription drug formulary applicable to your plan. To obtain a prescription medication that is not included on this formulary, your provider must
complete the 'Prescription Drug Medication Request Form' and return it to the Pharmacy Affairs Department for clinical review. Under the mandatory generic provision, you are responsible for the payment
differential when a generic drug is available and you or your provider specifies a brand name drug. Your payment is the price difference between the brand name drug and the generic drug in addition to the
brand name drug coinsurance amounts, which may apply.
(8) Certain retail participating pharmacy providers may have agreed to make covered medications available at the same cost-sharing and quantity limits as the mail order coverage. You may contact Highmark at
the toll-free number or the Web site appearing on the back of your ID card for a listing of those pharmacies who have agreed to do so.
(9) Services are provided for acute care for minor illnesses. Services must be performed by a Highmark approved telemedicine provider. Virtual Behavioral Health visits provided by a Highmark approved
telemedicine provider are eligible under the Outpatient Mental Health benefit.

This is not a contract. This benefits summary presents plan highlights only. Please refer to the policy/plan documents, as limitations and exclusions apply. The policy/ plan documents control in the event of a
conflict with this benefits summary

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