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

Pharmacy BenefitPRIMARY COVERAGE UNDER ANOTHER PLANWhen primary coverage exists under another Plan, including Medicare Part D, charges for prescriptiondrugs may be reimbursed by the Plan as specifically stated in this section, subject to the followingconditions:1. The prescription drug receipt and explanation of benefits from primary carrier (if applicable) issubmitted to the Plan, along with a reimbursement form to Allegiance Benefit Plan Management,Inc.2. The pharmacy indicates either “generic” or “brand” on the prescription drug receipt.3. The primary coverage information has been previously submitted to the Plan.Charges for prescription drugs are not eligible if the above conditions are not met.SUPPLY LIMITSSupply is limited as follows:PBM Network Prescriptions and Member Submit: 30 daysIn-house Pharmacies, including Specialty drugs: 34 daysMail Order: 90-days.Prescription drug refills are not allowed until 75% of the prescribed day supply is used.PRIOR AUTHORIZATIONCertain drugs require approval before the drug can be dispensed. A current list of drugs that require priorauthorization can be obtained by contacting the PBM at the number listed on your identification card.EXCLUSIONSPrescription drugs or supplies in the following categories are specifically excluded:1. Cosmetic only indications, including but not limited to, photo-aged skin products (Renova); HairGrowth Agents (Propecia, Vaniqa); Injectable cosmetics (botox cosmetic); and depigmentationproducts (Eldoquin, Lustra).2. Dermatology: Tretinoin agents used in the treatment of acne and/or for cosmetic purposes (RetinA) for Covered Persons 26 years or older.3. Legend homeopathic drugs.4. Fertility agents, oral, vaginal and injectable.5. Erectile dysfunction.6. Weight management, except as specifically covered.7. Serums, toxoids and vaccines.Western Montana Providence Health & Services - SPD 14Group #2000204 - January 1, 2011