I:\Legal\LEGAL\ST PATRICK HOSPITAL-Medical\Plan Document ...

Pharmacy BenefitWhen Primary Coverage exists Under Another PlanIf primary coverage exists under another plan, including Medicare Part D, charges for prescriptiondrugs must be submitted to the primary carrier first. Once this Plan receives a copy of the drugreceipt or explanation of benefits showing the total charges and amounts paid for eligibleprescription drugs from the primary carrier, if applicable, this Plan will reimburse the Participant forthe remainder of Maximum Eligible Expenses or Procedure Based Limit, subject to the followingcopayments:Generic ................................................................... $15Brand Name ............................................................... $25In order to receive reimbursement, the drug receipt must be submitted to Allegiance.COST SHARING PROVISIONS (ProvSelect HSA)Subject to Medical Deductible and Out-of-Pocket Maximum. Copayments apply as follows:Copayment per Prescription:Generic Preventive Prescriptions ................... No Copayment applies. Paid at 100%*Generic non-preventive and Brand ............................................ 20%**COVERAGE*A list of generic preventive prescriptions is available from the PBM.**Copayment applies after satisfaction of the Medical Benefits Deductible until satisfaction of theMedical Out-of-Pocket Maximum.Coverage for prescription drugs will include only those drugs requiring a written prescription of a Physicianor Licensed Health Care Provider, if within the scope of practice of the Licensed Health Care Provider, andthat are Medically Necessary for the treatment of an Illness or Injury.Coverage also includes prescription drugs or supplies that require a written prescription of a Physician orLicensed Health Care Provider, if within the scope of practice of the Licensed Health Care Provider, asfollows:1. Self-administered contraceptives.2. Legend vitamins (oral only): Prenatal agents used in pregnancy.3. Legend fluoride products (oral only): Adult and pediatric.4. Weight management: Amphetamines - agents used to suppress appetite (Bontril, Adioex,Phentermine) through eighteen years of age.5. Smoking cessation products: legend or over-the-counter, limited to $150 Maximum LifetimeBenefit6. Diabetic supplies, including syringes, needles, swabs, blood test strips (glucose or ketone), bloodglucose calibration solutions, urine tests, lancets and lancet devices.Western Montana Providence Health & Services - SPD 12Group #2000204 - January 1, 2011