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SECTION 13 - Prescription Drug

What this section includes:
· Coverage policies and guidelines
· Identification card (ID Card) – Network Pharmacy
· When Do We Limit Selection of Pharmacies?
· Benefits for prescription drug products
· What Happens When a Brand name Drug Becomes Available as a Generic?
· How Do Supply Limits Apply?
· Special Programs
· Prior Authorization Requirements
· Specialty Prescription Drug Products
· Does Step Therapy Apply?
· Rebates and other payments
· Coupons, Incentives and Other Communications
· Exclusions
Coverage Policies and Guidelines

Our Prescription Drug List (PDL) Management Committee makes tier placement changes on our behalf. The PDL
Management Committee places FDA-approved Prescription Drug Products into tiers by considering a number of
factors including clinical and economic factors. Clinical factors may include, review of the place in therapy, or use
as compared to other similar product or services, site of care, relative safety or effectiveness of the Prescription
Drug Product, as well as if supply limits or notification requirements should apply. Economic factors may include
the Prescription Drug Product’s total cost including any rebates and evaluations on the cost effectiveness of the
Prescription Drug Product.

Some Prescription Drug Products are more cost effective for treating specific conditions than others; therefore, a
Prescription Drug Product may be placed on multiple tiers according to the condition for which the Prescription
Drug Product was prescribed to treat.
We may from time to time change the placement of a Prescription Drug Product among the tiers. These changes
generally will happen twice a year, but no more than six times per Calendar Year. These changes may happen
without prior notice to you.

When considering a Prescription Drug Product for tier placement, the PDL Management Committee reviews
clinical and economic factors regarding Covered Persons as a general population. Whether a particular
Prescription Drug Product is appropriate for you is a determination that is made by you and your prescribing
Physician.
Note: The tier placement of a Prescription Drug Product may change from time to time based on the process
described above. As a result of such changes, you may be required to pay more or less for that Prescription Drug
Product. Please contact us at www.myallsavers.com or the telephone number on your ID card for the most up-to-
date tier placement.

Identification Card (ID Card) - Network Pharmacy
You must either show your ID card at the time you obtain your Prescription Drug Product at a Network Pharmacy
or you must provide the Network Pharmacy with identifying information that can be verified by us during regular
business hours.

If you do not show your ID card or provide verifiable information at a Network Pharmacy, you must pay the Usual
and Customary Charge for the Prescription Drug Product at the pharmacy.
You may pay more if you did not verify your eligibility when the Prescription Drug Product was dispensed or when
you utilize an out-of-network pharmacy. You may be required to submit your claim to the pharmacy address on
the back of your ID card. The amount you are reimbursed will be based on the Prescription Drug Cost, less the
required Copayment and/or Coinsurance, Ancillary Charge and any deductible that applies.

Smart Fill Program - Split Fill
Certain Specialty Prescription Drug Products may be dispensed by the Designated Pharmacy in 15-day supplies
up to 90 days and at a pro-rated Co-payment or Co-insurance. You will receive a 15-day supply of their Specialty
Prescription Drug Product to find out if you will tolerate the Specialty Prescription Drug Product prior to purchasing
a full supply. The Designated Pharmacy will contact you each time prior to dispensing the 15-day supply to

Page 68 Section 13 -Prescription Drug
PPO - 2017