Common use of Designated Providers Clause in Contracts

Designated Providers. If you have a medical condition that we believe needs special services, we may direct you to a Designated Provider chosen by us. If you require certain complex Covered Health Care Services for which expertise is limited, we may direct you to a Network facility or provider that is outside your local geographic area. In both cases, Benefits will only be paid if your Covered Health Care Services for that condition are provided by or arranged by the Designated Provider chosen by us. You or your Network Physician must notify us of special service needs (such as transplants) that might warrant referral to a Designated Provider. If you do not notify us in advance, and if you receive services from an out-of- Network facility (regardless of whether it is a Designated Provider) or other out-of-Network provider, Benefits will not be paid. If specific Covered Health Care Services are not available from a Network provider, you may be eligible for Benefits when Covered Health Care Services are received from out-of-Network providers. In this situation, your Network Physician will notify us and, if we confirm that care is not available from a Network provider, we will work with you and your Network Physician to coordinate care through an out-of-Network provider. Benefits are available for Prescription Drug Products at a Network Pharmacy and are subject to Co-payments and/or Co-insurance 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. If a Generic becomes available for a Brand-name Prescription Drug Product, the tier placement of the Brand-name Prescription Drug Product may change. Therefore, your Co-payment and/or Co-insurance may change or you will no longer have Benefits for that particular Brand-name Prescription Drug Product. Benefits for Prescription Drug Products are subject to the supply limits that are stated in the "Description and Supply Limits" column of the Benefit Information table. For a single Co-payment and/or Co-insurance, you may receive a Prescription Drug Product up to the stated supply limit. SAMPLE Note: Some products are subject to additional supply limits based on criteria that we have developed. Supply limits are subject, from time to time, to our review and change. This may limit the amount dispensed per Prescription Order or Refill and/or the amount dispensed per month's supply, or may require that a minimum amount be dispensed. You may find out whether a Prescription Drug Product has a supply limit for dispensing by contacting us at ▇▇▇.▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇ or the telephone number on your ID card. Before certain Prescription Drug Products are dispensed to you, you are required to obtain prior authorization from us or our designee. The reason for obtaining prior authorization from us is to determine whether the Prescription Drug Product, in accordance with our approved guidelines, is each of the following: • It meets the definition of a Covered Health Care Service. • It is not an Experimental or Investigational or Unproven Service. We may also require you to obtain prior authorization from us or our designee so we can determine whether the Prescription Drug Product, in accordance with our approved guidelines, was prescribed by a Specialist. If you do not obtain prior authorization from us before the Prescription Drug Product is dispensed, you will be responsible for paying all charges and no Benefits will be paid. The Prescription Drug Products requiring prior authorization are subject, from time to time, to our review and change. There may be certain Prescription Drug Products that require you to notify us directly rather than your Physician or pharmacist. You may find out whether a particular Prescription Drug Product requires notification/prior authorization by contacting us at ▇▇▇.▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇ or the telephone number on your ID card. If you do not obtain prior authorization from us before the Prescription Drug Product is dispensed, you can ask us to consider reimbursement after you receive the Prescription Drug Product. You will be required to pay for the Prescription Drug Product at the pharmacy. You may seek reimbursement from us as described in the Policy in Section 5: How to File a Claim. When you submit a claim on this basis, you may pay more because you did not obtain prior authorization from us before the Prescription Drug Product was dispensed. The amount you are reimbursed will be based on the Prescription Drug Charge, less the required Co-payment and/or Co-insurance and any deductible that applies. Benefits may not be available for the Prescription Drug Product after we review the documentation provided and we determine that the Prescription Drug Product is not a Covered Health Care Service or it is an Experimental or Investigational or Unproven Service. We may also require prior authorization for certain programs which may have specific requirements for participation and/or activation of an enhanced level of Benefits related to such programs. You may access information on available programs and any applicable prior authorization, participation or activation requirements related to such programs by contacting us at ▇▇▇.▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇ or the telephone number on your ID card. Certain Prescription Drug Products for which Benefits are described under Section 10: Outpatient Prescription Drugs of the Policy are subject to step therapy requirements. In order to receive Benefits for such Prescription Drug Products you must use a different Prescription Drug Product(s) first. You may find out whether a Prescription Drug Product is subject to step therapy requirements by contacting us at ▇▇▇.▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇ or the telephone number on your ID card. When a Prescription Drug Product is not listed on the PDL, you or your representative may request an exception to gain access to the excluded Prescription Drug Product. To make a request, contact us in writing or call the toll-free number on your ID card. We will notify you of our determination within 72 hours. Please note, if your request for an exception is approved by us, you may be responsible for paying the applicable Co- payment and/or Co-insurance based on the Prescription Drug Product tier placement, or at the second highest tier. For example, if you have a 5-tier plan, then the 4th tier would be considered the second highest tier.

Designated Providers. If you have a medical condition that we believe needs special services, we may direct you to a Designated Provider chosen by us. If you require certain complex Covered Health Care Services for which expertise is limited, we may direct you to a Network facility or provider that is outside your local geographic area. If you are required to travel to obtain such Covered Health Care Services from a Designated Provider, we may reimburse certain travel expenses. In both cases, Benefits will only be paid if your Covered Health Care Services for that condition are provided by or arranged by the Designated Provider chosen by us. You or your Network Physician must notify us of special service needs (such as transplantstransplants or morbid obesity surgery) that might warrant referral to a Designated Provider. If you do not notify us in advance, and if you receive services from an out-of- of-Network facility (regardless of whether it is a Designated Provider) or other out-of-Network provider, Benefits will not be paid. SAMPLE If specific Covered Health Care Services are not available from a Network provider, you may be eligible for Benefits when Covered Health Care Services are received from out-of-Network providers. In this situation, your Network Physician will notify us and, if we confirm that care is not available from a Network provider, we will work with you and your Network Physician to coordinate care through an out-of-Network provider. Benefits are available for Prescription Drug Products at a Network Pharmacy and are subject to Co-payments and/or Co-insurance 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. If a Generic becomes available for a Brand-name Prescription Drug Product, the tier placement of the Brand-name Prescription Drug Product may change. Therefore, your Co-payment and/or Co-insurance may change or you will no longer have Benefits for that particular Brand-name Prescription Drug Product. Benefits for Prescription Drug Products are subject to the supply limits that are stated in the "Description and Supply Limits" column of the Benefit Information table. For a single Co-payment and/or Co-insurance, you may receive a Prescription Drug Product up to the stated supply limit. SAMPLE Note: Some products are subject to additional supply limits based on criteria that we have developed. Supply limits are subject, from time to time, to our review and change. This may limit the amount dispensed per Prescription Order or Refill and/or the amount dispensed per month's supply, or may require that a minimum amount be dispensed. You cannot refill a prescription until 75% of the supply has been used except under certain circumstances during a state of emergency or disaster. You may find out whether a Prescription Drug Product has a supply limit for dispensing by contacting us at ▇▇▇.▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇ or the telephone number on your ID card. Before certain Prescription Drug Products are dispensed to you, you are required to obtain prior authorization from us or our designee. The reason for obtaining prior authorization from us is to determine whether the Prescription Drug Product, in accordance with our approved guidelines, is each of the following: • It meets the definition of a Covered Health Care Service. • It is not an Experimental or Investigational or Unproven Service. We may also require you to obtain prior authorization from us or our designee so we can determine whether the Prescription Drug Product, in accordance with our approved guidelines, was prescribed by a Specialist. If you do not obtain prior authorization from us before the Prescription Drug Product is dispensed, you will be responsible for paying all charges and no Benefits will be paid. The Prescription Drug Products requiring prior authorization are subject, from time to time, to our review and change. There may be certain Prescription Drug Products that require you to notify us directly rather than your Physician or pharmacist. You may find out whether a particular Prescription Drug Product requires notification/prior authorization by contacting us at ▇▇▇.▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇ or the telephone number on your ID card. If you do not obtain prior authorization from us before the Prescription Drug Product is dispensed, you can ask us to consider reimbursement after you receive the Prescription Drug Product. You will be required to pay for the Prescription Drug Product at the pharmacy. You may seek reimbursement from us as described in the Policy in Section 5: How to File a Claim. When you submit a claim on this basis, you may pay more because you did not obtain prior authorization from us before the Prescription Drug Product was dispensed. The amount you are reimbursed will be based on the Prescription Drug Charge, less the required Co-payment and/or Co-insurance and any deductible that applies. Benefits may not be available for the Prescription Drug Product after we review the documentation provided and we determine that the Prescription Drug Product is not a Covered Health Care Service or it is an Experimental or Investigational or Unproven Service. We may also require prior authorization for certain programs which may have specific requirements for participation and/or activation of an enhanced level of Benefits related to such programs. You may access information on available programs and any applicable prior authorization, participation or activation requirements related to such programs by contacting us at ▇▇▇.▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇ or the telephone number on your ID card. Certain Prescription Drug Products for which Benefits are described under Section 10: Outpatient Prescription Drugs of the Policy are subject to step therapy requirements. In order to receive Benefits for such Prescription Drug Products you must use a different Prescription Drug Product(s) first. You may find out whether a Prescription Drug Product is subject to step therapy requirements by contacting us at ▇▇▇.▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇ or the telephone number on your ID card. When a Prescription Drug Product is not listed on the PDL, you or your representative may request an exception to gain access to the excluded Prescription Drug Product. To make a request, contact us in writing or call the toll-free number on your ID card. We will notify you of our determination within 72 hours. Please note, if your request for an exception is approved by us, you may be responsible for paying the applicable Co- payment and/or Co-insurance based on the Prescription Drug Product tier placement, or at the second highest tier. For example, if you have a 5-tier plan, then the 4th tier would be considered the second highest tier.

Designated Providers. If you have a medical condition that we believe needs special services, we may direct you to a Designated Provider chosen by us. If you require certain complex Covered Health Care Services for which expertise is limited, we may direct you to a Network facility or provider that is outside your local geographic area. If you are required to travel to obtain such Covered Health Care Services from a Designated Provider, we may reimburse certain travel expenses. In both cases, Benefits will only be paid if your Covered Health Care Services for that condition are provided by or arranged by the Designated Provider chosen by us. You or your Network Physician must notify us of special service needs (such as transplantstransplants or morbid obesity surgery) that might warrant referral to a Designated Provider. If you do not notify us in advance, and if you receive services from an out-of- of-Network facility (regardless of whether it is a Designated Provider) or other out-of-Network provider, Benefits will not be paid. If specific Covered Health Care Services are not available from a Network provider, you may be eligible for Benefits when Covered Health Care Services are received from out-of-Network providers. In this situation, your Network Physician will notify us and, if we confirm that care is not available from a Network provider, we will work with you and your Network Physician to coordinate care through an out-of-Network provider. SAMPLE If Behavioral Health Care Services are not available from a Network provider in a Timely Manner, you will be eligible to receive Covered Health Care Services from an out-of-Network provider at the same cost share as if received from a Network Provider. In this situation, we will work with you to coordinate care through an out-of-Network provider in a Timely Manner as defined within the Policy. Benefits are available for Prescription Drug Products at a Network Pharmacy and are subject to Co-payments and/or Co-insurance 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. If a Generic becomes available for a Brand-name Prescription Drug Product, the tier placement of the Brand-name Prescription Drug Product may change. Therefore, your Co-payment and/or Co-insurance may change or you will no longer have Benefits for that particular Brand-name Prescription Drug Product. Benefits for Prescription Drug Products are subject to the supply limits that are stated in the "Description and Supply Limits" column of the Benefit Information table. For a single Co-payment and/or Co-insurance, you may receive a Prescription Drug Product up to the stated supply limit. SAMPLE Note: Some products are subject to additional supply limits based on criteria that we have developed. Supply limits are subject, from time to time, to our review and change. This may limit the amount dispensed per Prescription Order or Refill and/or the amount dispensed per month's supply, or may require that a minimum amount be dispensed. You may find out whether a Prescription Drug Product has a supply limit for dispensing by contacting us at ▇▇▇.▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇ or the telephone number on your ID card. Before certain Prescription Drug Products are dispensed to you, you are required to obtain prior authorization from us or our designee. The reason for obtaining prior authorization from us is to determine whether the Prescription Drug Product, in accordance with our approved guidelines, is each of the following: • It meets the definition of a Covered Health Care Service. • It is not an Experimental or Investigational or Unproven Service. We may also require you to obtain prior authorization from us or our designee so we can determine whether the Prescription Drug Product, in accordance with our approved guidelines, was prescribed by a Specialist. If you do not obtain prior authorization from us before the Prescription Drug Product is dispensed, you will be responsible for paying all charges and no Benefits will be paid. The Prescription Drug Products requiring prior authorization are subject, from time to time, to our review and change. There may be certain Prescription Drug Products that require you to notify us directly rather than your Physician or pharmacist. You may find out whether a particular Prescription Drug Product requires notification/prior authorization by contacting us at ▇▇▇.▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇ or the telephone number on your ID card. If you do not obtain prior authorization from us before the Prescription Drug Product is dispensed, you can ask us to consider reimbursement after you receive the Prescription Drug Product. You will be required to pay for the Prescription Drug Product at the pharmacy. You may seek reimbursement from us as described in the Policy in Section 5: How to File a Claim. When you submit a claim on this basis, you may pay more because you did not obtain prior authorization from us before the Prescription Drug Product was dispensed. The amount you are reimbursed will be based on the Prescription Drug Charge, less the required Co-payment and/or Co-insurance and any deductible that applies. Benefits may not be available for the Prescription Drug Product after we review the documentation provided and we determine that the Prescription Drug Product is not a Covered Health Care Service or it is an Experimental or Investigational or Unproven Service. We may also require prior authorization for certain programs which may have specific requirements for participation and/or activation of an enhanced level of Benefits related to such programs. You may access information on available programs and any applicable prior authorization, participation or activation requirements related to such programs by contacting us at ▇▇▇.▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇ or the telephone number on your ID card. Certain Prescription Drug Products for which Benefits are described under Section 10: Outpatient Prescription Drugs of the Policy are subject to step therapy requirements. In order to receive Benefits for such Prescription Drug Products you must use a different Prescription Drug Product(s) first. You may find out whether a Prescription Drug Product is subject to step therapy requirements by contacting us at ▇▇▇.▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇ or the telephone number on your ID card. When a Prescription Drug Product is not listed on the PDL, you or your representative may request an exception to gain access to the excluded Prescription Drug Product. To make a request, contact us in writing or call the toll-free number on your ID card. We will notify you of our determination within 72 hours. Please note, if your request for an exception is approved by us, you may be responsible for paying the applicable Co- payment and/or Co-insurance based on the Prescription Drug Product tier placement, or at the second highest tier. For example, if you have a 5-tier plan, then the 4th tier would be considered the second highest tier.

Designated Providers. If you have a medical condition that we believe needs special services, we may direct you to a Designated Provider chosen by us. If you require certain complex Covered Health Care Services for which expertise is limited, we may direct you to a Network facility or provider that is outside your local geographic area. If you are required to travel to obtain such Covered Health Care Services from a Designated Provider, we may reimburse certain travel expenses. In both cases, Benefits will only be paid if your Covered Health Care Services for that condition are provided by or arranged by the Designated Provider chosen by us. You or your Network Physician must notify us of special service needs (such as transplantstransplants or morbid obesity surgery) that might warrant referral to a Designated Provider. If you do not notify us in advance, and if you receive services from an out-of- of-Network facility (regardless of whether it is a Designated Provider) or other out-of-Network provider, Benefits will not be paid. SAMPLE If specific Covered Health Care Services are not available from a Network provider, you may be eligible for Benefits when Covered Health Care Services are received from out-of-Network providers. In this situation, your Network Physician will notify us and, if we confirm that care is not available from a Network provider, we will work with you and your Network Physician to coordinate care through an out-of-Network provider. If you receive a Covered Health Care Service from an out-of-Network provider as a result of an Emergency or if we refer you to an out-of-Network provider, we will reimburse you for any out-of-Network cost you incurred that you would not have otherwise incurred if you had received the Covered Health Care Service from a Network provider. This means if the out-of-Network provider bills and seeks to collect from you amounts in excess of our payment, please call the telephone number on your health insurance identification card, and we will commence negotiation with the out-of-Network provider. We will not pay excessive charges or amounts that you are not legally obligated to pay. A Network exception does not include Benefits if you decide to go out-of-Network for Covered Health Care Services. Network exceptions must be arranged by us. Benefits are available for Prescription Drug Products at a Network Pharmacy and are subject to Co-payments and/or Co-insurance 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. If a Generic becomes available for a Brand-name Prescription Drug Product, the tier placement of the Brand-name Prescription Drug Product may change. Therefore, your Co-payment and/or Co-insurance may change or you will no longer have Benefits for that particular Brand-name Prescription Drug Product. Benefits for Prescription Drug Products are subject to the supply limits that are stated in the "Description and Supply Limits" column of the Benefit Information table. For a single Co-payment and/or Co-insurance, you may receive a Prescription Drug Product up to the stated supply limit. SAMPLE Note: Some products are subject to additional supply limits based on criteria that we have developed. Supply limits are subject, from time to time, to our review and change. This may limit the amount dispensed per Prescription Order or Refill and/or the amount dispensed per month's supply, or may require that a minimum amount be dispensed. You may find out whether a Prescription Drug Product has a supply limit for dispensing by contacting us at ▇▇▇.▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇ or the telephone number on your ID card. Before certain Prescription Drug Products are dispensed to you, you are your Physician is required to obtain prior authorization from us or our designee. The reason for obtaining prior authorization from us is to determine whether the Prescription Drug Product, in accordance with our approved guidelines, is each of the following: • It meets the definition of a Covered Health Care Service. • It is not an Experimental or Investigational or Unproven Serviceunproven service. We may also require you your Physician to obtain prior authorization from us or our designee so we can determine whether the Prescription Drug Product, in accordance with our approved guidelines, was prescribed by a Specialist. If you do your Physician does not obtain prior authorization from us before the Prescription Drug Product is dispensed, you will be responsible for paying all charges and no Benefits will be paid. The Prescription Drug Products requiring prior authorization are subject, from time to time, to our review and change. There may be certain Prescription Drug Products that require you to notify us directly rather than your Physician or pharmacist. You may find out whether a particular Prescription Drug Product requires notification/prior authorization by contacting us at ▇▇▇.▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇ or the telephone number on your ID card. If you do your Physician does not obtain prior authorization from us before the Prescription Drug Product is dispensed, you can ask us to consider reimbursement after you receive the Prescription Drug Product. You will be required to pay for the Prescription Drug Product at the pharmacy. You may seek reimbursement from us as described in the Policy in Section 5: How to File a Claim. When you submit a claim on this basis, you may pay more because you your Physician did not obtain prior authorization from us before the Prescription Drug Product was dispensed. The amount you are reimbursed will be based on the Prescription Drug Charge, less the required Co-payment and/or Co-insurance and any deductible that applies. Benefits may not be available for the Prescription Drug Product after we review the documentation provided and we determine that the Prescription Drug Product is not a Covered Health Care Service or it is an Experimental or Investigational or Unproven Serviceunproven service. We may also require prior authorization for certain programs which may have specific requirements for participation and/or activation of an enhanced level of Benefits related to such programs. You may access information on available programs and any applicable prior authorization, participation or activation requirements related to such programs by contacting us at ▇▇▇.▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇ or the telephone number on your ID card. Certain Prescription Drug Products for which Benefits are described under Section 10: the Outpatient Prescription Drugs section of the Policy are subject to step therapy requirements. In order to receive Benefits for such Prescription Drug Products you must use a different Prescription Drug Product(s) first. You may find out whether a Prescription Drug Product is subject to step therapy requirements by contacting us at ▇▇▇.▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇ or the telephone number on your ID card. When a Prescription Drug Product is not listed on the PDL, you or your representative may request an exception to gain access to the excluded Prescription Drug Product. To make a request, contact us in writing or call the toll-free number on your ID card. We will notify you of our determination within 72 hours. Please note, if your request for an exception is approved by us, you may be responsible for paying the applicable Co- payment and/or Co-insurance based on the Prescription Drug Product tier placement, or at the second highest tier. For example, if you have a 5-tier plan, then the 4th tier would be considered the second highest tier. Benefits for contraceptives and PrEP are covered at no cost to you. SAMPLE If your request requires immediate action and a delay could significantly increase the risk to your health, or the ability to regain maximum function, call us as soon as possible. We will provide a written or electronic determination within 24 hours.

Designated Providers. If you have a medical condition that we believe needs special services, we may direct you to a Designated Provider chosen by us. If you require certain complex Covered Health Care Services for which expertise is limited, we may direct you to a Network facility or provider that is outside your local geographic area. If you are required to travel to obtain such Covered Health Care Services from a Designated Provider, we may reimburse certain travel expenses. In both cases, Benefits will only be paid if your Covered Health Care Services for that condition are provided by or arranged by the Designated Provider chosen by us. You or your Network Physician must notify us of special service needs (such as transplantstransplants or morbid obesity surgery) that might warrant referral to a Designated Provider. If you do not notify us in advance, and if you receive services from an out-of- of-Network facility (regardless of whether it is a Designated Provider) or other out-of-Network provider, Benefits will not be paid. If specific Covered Health Care Services are not available from a Network provider, you may be eligible for Benefits when Covered Health Care Services are received from out-of-Network providers. In this situation, your Network Physician will notify us and, if we confirm that care is not available from a Network provider, we will work with you and your Network Physician to coordinate care through an out-of-Network provider. SAMPLE If Behavioral Health Care Services are not available from a Network provider in a Timely Manner, you will be eligible to receive Covered Health Care Services from an out-of-Network provider at the same cost share as if received from a Network Provider. In this situation, we will work with you to coordinate care through an out-of-Network provider in a Timely manner as defined within the Policy. Benefits are available for Prescription Drug Products at a Network Pharmacy and are subject to Co-payments and/or Co-insurance 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. If a Generic becomes available for a Brand-name Prescription Drug Product, the tier placement of the Brand-name Prescription Drug Product may change. Therefore, your Co-payment and/or Co-insurance may change or you will no longer have Benefits for that particular Brand-name Prescription Drug Product. Benefits for Prescription Drug Products are subject to the supply limits that are stated in the "Description and Supply Limits" column of the Benefit Information table. For a single Co-payment and/or Co-insurance, you may receive a Prescription Drug Product up to the stated supply limit. SAMPLE Note: Some products are subject to additional supply limits based on criteria that we have developed. Supply limits are subject, from time to time, to our review and change. This may limit the amount dispensed per Prescription Order or Refill and/or the amount dispensed per month's supply, or may require that a minimum amount be dispensed. You may find out whether a Prescription Drug Product has a supply limit for dispensing by contacting us at ▇▇▇.▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇ or the telephone number on your ID card. Before certain Prescription Drug Products are dispensed to you, you are required to obtain prior authorization from us or our designee. The reason for obtaining prior authorization from us is to determine whether the Prescription Drug Product, in accordance with our approved guidelines, is each of the following: • It meets the definition of a Covered Health Care Service. • It is not an Experimental or Investigational or Unproven Service. We may also require you to obtain prior authorization from us or our designee so we can determine whether the Prescription Drug Product, in accordance with our approved guidelines, was prescribed by a Specialist. If you do not obtain prior authorization from us before the Prescription Drug Product is dispensed, you will be responsible for paying all charges and no Benefits will be paid. The Prescription Drug Products requiring prior authorization are subject, from time to time, to our review and change. There may be certain Prescription Drug Products that require you to notify us directly rather than your Physician or pharmacist. You may find out whether a particular Prescription Drug Product requires notification/prior authorization by contacting us at ▇▇▇.▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇ or the telephone number on your ID card. If you do not obtain prior authorization from us before the Prescription Drug Product is dispensed, you can ask us to consider reimbursement after you receive the Prescription Drug Product. You will be required to pay for the Prescription Drug Product at the pharmacy. You may seek reimbursement from us as described in the Policy in Section 5: How to File a Claim. When you submit a claim on this basis, you may pay more because you did not obtain prior authorization from us before the Prescription Drug Product was dispensed. The amount you are reimbursed will be based on the Prescription Drug Charge, less the required Co-payment and/or Co-insurance and any deductible that applies. Benefits may not be available for the Prescription Drug Product after we review the documentation provided and we determine that the Prescription Drug Product is not a Covered Health Care Service or it is an Experimental or Investigational or Unproven Service. We may also require prior authorization for certain programs which may have specific requirements for participation and/or activation of an enhanced level of Benefits related to such programs. You may access information on available programs and any applicable prior authorization, participation or activation requirements related to such programs by contacting us at ▇▇▇.▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇ or the telephone number on your ID card. Certain Prescription Drug Products for which Benefits are described under Section 10: the Outpatient Prescription Drugs section of the Policy are subject to step therapy requirements. In order to receive Benefits for such Prescription Drug Products you must use a different Prescription Drug Product(s) first. You may find out whether a Prescription Drug Product is subject to step therapy requirements by contacting us at ▇▇▇.▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇ or the telephone number on your ID card. When a Prescription Drug Product is not listed on the PDL, you or your representative may request an exception to gain access to the excluded Prescription Drug Product. To make a request, contact us in writing or call the toll-free number on your ID card. We will notify you of our determination within 72 hours. Please note, if your request for an exception is approved by us, you may be responsible for paying the applicable Co- payment and/or Co-insurance based on the Prescription Drug Product tier placement, or at the second highest tier. For example, if you have a 5-tier plan, then the 4th tier would be considered the second highest tier.

Designated Providers. If you have a medical condition that we believe needs special services, we may direct you to a Designated Provider chosen by us. If you require certain complex Covered Health Care Services for which expertise is limited, we may direct you to a Network facility or provider that is outside your local geographic area. In both cases, Benefits will only be paid if your Covered Health Care Services for that condition are provided by or arranged by the Designated Provider chosen by us. SAMPLE You or your Network Physician must notify us of special service needs (such as transplantstransplants or morbid obesity surgery) that might warrant referral to a Designated Provider. If you do not notify us in advance, and if you receive services from an out-of- of-Network facility (regardless of whether it is a Designated Provider) or other out-of-Network provider, Benefits will not be paid. If specific Covered Health Care Services are not available from a Network provider, you may be eligible for Benefits when Covered Health Care Services are received from out-of-Network providers. In this situation, your Network Physician will notify us and, if we confirm that care is not available from a Network provider, we will work with you and your Network Physician to coordinate care through an out-of-Network provider. Benefits are available for Prescription Drug Products at a Network Pharmacy and are subject to Co-payments and/or Co-insurance 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. If a Generic becomes available for a Brand-name Prescription Drug Product, the tier placement of the Brand-name Prescription Drug Product may change. Therefore, your Co-payment and/or Co-insurance may change or you will no longer have Benefits for that particular Brand-name Prescription Drug Product. Benefits for Prescription Drug Products are subject to the supply limits that are stated in the "Description and Supply Limits" column of the Benefit Information table. For a single Co-payment and/or Co-insurance, you may receive a Prescription Drug Product up to the stated supply limit. SAMPLE Note: Some products are subject to additional supply limits based on criteria that we have developed. Supply limits are subject, from time to time, to our review and change. This may limit the amount dispensed per Prescription Order or Refill and/or the amount dispensed per month's supply, or may require that a minimum amount be dispensed. You may find out whether a Prescription Drug Product has a supply limit for dispensing by contacting us at ▇▇▇.▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇ or the telephone number on your ID card. Before certain Prescription Drug Products are dispensed to you, you are required to obtain prior authorization from us or our designee. The reason for obtaining prior authorization from us is to determine whether the Prescription Drug Product, in accordance with our approved guidelines, is each of the following: • It meets the definition of a Covered Health Care Service. • It is not an Experimental or Investigational or Unproven Service. We may also require you to obtain prior authorization from us or our designee so we can determine whether the Prescription Drug Product, in accordance with our approved guidelines, was prescribed by a Specialist. If you do not obtain prior authorization from us before the Prescription Drug Product is dispensed, you will be responsible for paying all charges and no Benefits will be paid. The Prescription Drug Products requiring prior authorization are subject, from time to time, to our review and change. There may be certain Prescription Drug Products that require you to notify us directly rather than your Physician or pharmacist. You may find out whether a particular Prescription Drug Product requires notification/prior authorization by contacting us at ▇▇▇.▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇ or the telephone number on your ID card. If you do not obtain prior authorization from us before the Prescription Drug Product is dispensed, you can ask us to consider reimbursement after you receive the Prescription Drug Product. You will be required to pay for the Prescription Drug Product at the pharmacy. You may seek reimbursement from us as described in the Policy in Section 5: How to File a Claim. When you submit a claim on this basis, you may pay more because you did not obtain prior authorization from us before the Prescription Drug Product was dispensed. The amount you are reimbursed will be based on the Prescription Drug Charge, less the required Co-payment and/or Co-insurance and any deductible that applies. Benefits may not be available for the Prescription Drug Product after we review the documentation provided and we determine that the Prescription Drug Product is not a Covered Health Care Service or it is an Experimental or Investigational or Unproven Service. We may also require prior authorization for certain programs which may have specific requirements for participation and/or activation of an enhanced level of Benefits related to such programs. You may access information on available programs and any applicable prior authorization, participation or activation requirements related to such programs by contacting us at ▇▇▇.▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇ or the telephone number on your ID card. Certain Prescription Drug Products for which Benefits are described under Section 10: the Outpatient Prescription Drugs section of the Policy are subject to step therapy requirements. In order to receive Benefits for such Prescription Drug Products you must use a different Prescription Drug Product(s) first. You may find out whether a Prescription Drug Product is subject to step therapy requirements by contacting us at ▇▇▇.▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇ or the telephone number on your ID card. When a Prescription Drug Product is not listed on the PDL, you or your representative may request an exception to gain access to the excluded Prescription Drug Product. To make a request, contact us in writing or call the toll-free number on your ID card. We will notify you of our determination within 72 hours. Please note, if your request for an exception is approved by us, you may be responsible for paying the applicable Co- payment and/or Co-insurance based on the Prescription Drug Product tier placement, or at the second highest tier. For example, if you have a 5-tier plan, then the 4th tier would be considered the second highest tier.