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Prior Authorization Requirements

Before certain Prescription Drug Products are dispensed to you, it is the responsibility of your Physician, your
pharmacist or you to obtain prior authorization. The reason for obtaining prior authorization is to determine if the
Prescription Drug Product is eligible for coverage. Medical Necessity goes beyond drug and diagnosis and takes
into consideration the clinical appropriateness of a medication in terms of condition being treated, severity of
conditions, type of medication, frequency of use, and duration of therapy. You may determine whether a
Prescription Drug Product requires prior authorization by contacting us at www.myallsavers.com or the telephone
number on your ID card.

Specialty Prescription Drug Products

Benefits are provided for Specialty Prescription Drug Products.
If you require Specialty Prescription Drug Products, we may direct you to a Designated Pharmacy with whom we
have an arrangement to provide those Specialty Prescription Drug Products. If you are directed to a Designated
Pharmacy and you choose not to obtain your Prescription Drug Product from a Designated Pharmacy, the
Prescription Drug Product is not eligible for benefits.

Does Step Therapy Apply?
In order to receive benefits for a Prescription Drug Product subject to step therapy requirements, the Claims
Administrator may require that your doctor first prescribe another Prescription Drug Product proven to be effective
for treatment of your condition. You may determine whether a particular Prescription Drug Product or
pharmaceutical product is subject to step therapy requirements by calling the phone number on your identification
card.
Rebates and Other Payments

We may receive rebates for certain drugs included on the Prescription Drug List. As determined by us, we may
pass a portion of these rebates on to you. When rebates are passed on to you, they may be taken into account in
determining your Deductible, Co-payment and/or Co-insurance.
We, and a number of our affiliated entities, conduct business with pharmaceutical manufacturers. Such business
may include, but is not limited to, data collection, consulting, educational grants and research. Amounts received
from pharmaceutical manufacturers pursuant to such arrangements are not related to this Prescription Drug
Benefit. We are not required to pass on to you, and do not pass on to you, such amounts.
Coupons, Incentives and Other Communications

At various times, we may send mailings or provide other communications to you, your Physician, or your
pharmacy that communicate a variety of messages, including information about Prescription and non-prescription
Drug Products. These communications may include offers that enable you, as you determine, to purchase the
described product at a discount. Pharmaceutical manufacturers or an affiliate may pay for and/or provide content
for these communications and offers. Only you and your Physician can determine whether a change in your
Prescription and/or non-prescription Drug regimen is appropriate for your medical condition.
Exclusions

Exclusions from coverage listed in the Summary Plan Description apply also to this section. The following will not
be considered Covered Health Care Services, and Benefits will not be available under this section for the
following:
· Prescription Drug Products obtained from an Out-of-Network Pharmacy;

· Prescription Drug Products for the amount dispensed (days' supply or quantity limit) which exceeds the
supply limit;
· Prescription Drug Products dispensed outside the United States, except as required for Emergency
treatment;
· Drugs which are prescribed, dispensed or intended for use during an Inpatient Stay;

· Experimental or Investigational Services or Unproven Services and medications; medications used for
experimental treatments for specific disease and/or dosage regimens determined by us to be
experimental, investigational or unproven. This exclusion does not apply to Prescription Drug Products
that have been approved by the U.S. Food and Drug Administration (FDA), but have not been approved

Page 70 Section 13 -Prescription Drug
HSA - 2017