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When Are Benefits Available for Prescription Drug Products?

Benefits are available for Prescription Drug Products at a Network Pharmacy and are subject to Copayments,
Annual Deductibles, and/or Coinsurance or other payments that vary depending on which of the tiers of the
Prescription Drug List the Prescription Drug Product is placed.

Benefits for Prescription Drug Products are available when the Prescription Drug Product meets the definition of a
Covered Health Care Service. Refer to Section 13, Prescription Drug for further coverage and exclusion
information.

What Do You Pay?

You are responsible for paying the applicable Copayment, Annual Deductible and/or Coinsurance. Benefits for
PPACA Zero Cost Share Preventive Care Medications are not subject to payment of the Annual Deductible,
Copayments and/or Coinsurance.

The amount you pay for the following under Section 13, Prescription Drug will not be included in calculating any
Out-of-Pocket Limit:

· Any non-covered drug product. You are responsible for paying 100% of the cost (the amount the
pharmacy charges you) for any non-covered drug product. Our contracted rates (our Prescription Drug
Cost) will not be available to you.
An Ancillary Charge may apply when a covered prescription drug product is dispensed at your or the provider’s
request and there is another drug that is chemically the same available. An Ancillary Charge does not apply to
any Out-of-Pocket Limit.

Page 18 Section 4 - Schedule of Benefits
PPO - 2017