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This Prescription Drug Rider (“Rider”) is made a part of Coventry Health and Life Insurance
Company’s Certificate of Coverage (“COC”). The benefits provided by this Rider become
effective on the date Coverage under the COC is effective.

Any capitalized terms used in this Rider and not otherwise defined herein shall have the meaning
set forth in the COC. The following definitions apply to this Rider:
Ancillary Charge. A charge in addition to the Copayment You are required to pay for a
Prescription Drug which, through Your request or that of the Prescribing Provider, has been
dispensed by the brand name, even though the Prescription Drug is subject to the MAC and
covered at the generic product level. The Ancillary Charge, if any, shall be the difference between
the Plan’s contracted price for the Non-Formulary or Formulary brand name drug and for the
Generic Drug. You are responsible at the time of service for payment of the Ancillary Charge
directly to the Participating Pharmacy.
Copayment. The amount You will be charged by the Pharmacy to dispense or refill any
Prescription. You are responsible at the time of service for payment of the Copayment directly to
the Pharmacy.
Covered Drugs. Prescription Drugs prescribed and approved by the Prescribing Provider and the
Plan subject to the specifications listed in this Rider.
Formulary. A list of specific generic and brand name Prescription Drugs Authorized by the Plan,
and subject to periodic review and modification. Since there may be more than one brand name of
a Prescription Drug, not all brands of the same Prescription Drug (e.g., different manufacturers)
may be included in the Formulary. The Formulary is available for review in the searchable
Formulary on Our website, in the Participating Provider’s office, or by
contacting the Customer Service Department.
Formulary Prescription Drug. A Prescription Drug that appears on the Plan’s Formulary.
Generic Prescription Drug. A Prescription Drug as being prescribed by its generic and chemical
name heading according to the principal ingredient(s) and approved by the Food and Drug
Mail Order List. A list of the Plan’s designated Formulary Maintenance Medications.
Mail Order Pharmacy. When applicable, the Pharmacy contracted by the Plan to provide
Maintenance Medications through the mail.
Maintenance Medication(s). Prescription Drugs, designated by the Plan and included on the Mail Order List, which are not written for episodic treatments of medical conditions. Maximum Allowable Cost (MAC). The price assigned to Prescription Drugs that will be covered at the generic product level, subject to periodic review and modification by the Plan. Non-Formulary Prescription Drug. A Prescription Drug that is not on the Plan’s list of Formulary Prescription Drugs. Non-Participating Pharmacy. Any pharmacy that is not a Participating Pharmacy as defined herein. Participating Pharmacy. A pharmacy licensed in the State in which it is located that has entered into a written contract with the Plan to provide services to the Plan’s Members, or on whose behalf a written contract has been made with the Plan which is in effect at the time services are provided. Prescribing Provider. Any person holding the degree of Doctor of Medicine, Doctor of Osteopathy, Doctor of Dental Medicine, or Doctor of Dental Surgery or any other provider who is duly licensed in the United States to prescribe medications in the ordinary course of his or her professional practice. Prescription Drug(s). Any medication or drug which: · is provided for outpatient administration; · has been approved by the Food and Drug Administration; and · under federal or state law, is dispensed pursuant to a prescription order (legend drug). This definition of Prescription Drug includes some over-the-counter medications or disposable medical supplies (e.g., insulin and diabetic supplies) and a compound substance when it meets the Plan’s criteria and the product is not available commercially. Prescription Order or Refill. The authorization for a legend Prescription Drug issued by a Prescribing Provider who is duly licensed to make such an authorization in the ordinary course of his or her professional practice. Pre-Certification. A process where the Plan or its designee determines, prior to dispensing, that a Prescription Order or Refill, otherwise Covered under this Rider, has been reviewed and, based upon information provided by the Prescribing Provider, the Prescription Order or Refill satisfies the requirements for Coverage. Self-Administered Injectable Drug(s). Self-Administered Injectable Prescription Drugs, as defined by the Plan, are commonly and customarily administered by the Member, and are available through a Specialty Pharmacy. Examples of Self-Administered Injectable Prescription Drugs include, but are not limited to, the following: multiple sclerosis agents, growth hormones, colony stimulating factors given more than once monthly, chronic medications for hepatitis C, certain rheumatoid arthritis medications, certain injectable HIV drugs, certain osteoporosis agents, and heparin products. Self-Administered Injectable Drug Copayment. The amount that will be charged to You by the Specialty Pharmacy to dispense or refill any Prescription Order or Refill for a Self-Administered Injectable Drug. You shall be required to pay one (1) Self-Administered Injectable Drug Copayment per each Prescription Order or Refill. You are responsible for payment of the Self-
Administered Injectable Drug Copayment directly to the Specialty Pharmacy at the time of service.
Note: For definition purposes, other injectable drugs, that are acquired through the retail Pharmacy,
are not considered Self-Administered Injectable Prescription Drugs, such as: insulin, glucagon, bee
sting kits, Imitrex and injectable contraceptives.
Specialty Pharmacy. A pharmacy that is designated as a Specialty Pharmacy by the Plan for
certain Prescription Orders or Refills.
Subject to the Limitations, Exclusions, Copayments and Ancillary Charges described below,
outpatient Prescription Drugs will be covered when:
· the Member is eligible to receive Covered Services;
· written by a Prescribing Provider; and · filled at a pharmacy, including a Mail Order Pharmacy or Specialty Pharmacy.
Generically equivalent pharmaceuticals will be dispensed whenever there is an FDA approved
generic drug. If you choose to receive a brand name Prescription Drug when a Generic Drug is
available, You will be responsible for the Ancillary Charge and the appropriate Copayment. The
Ancillary Charge will be due regardless of whether or not the Prescribing Provider indicates that
the pharmacy is to "Dispense as Written." Your total responsibility shall not exceed the average
wholesale price (“AWP”) of the Prescription Drug.

Non Participating Pharmacy. A Prescription Order or Refill may be obtained through a Non-
Participating Pharmacy, however, You may be required to pay for the cost of the Prescription
Drug(s) and file a claim for reimbursement. Payment for Prescription Drugs will be at a rate
consistent with that of a Participating Pharmacy less Your Copayment amount.
Pre-Certification and Specific Quantity Limits. Regardless of where a Prescription Order or
Refill is filled, Covered Drugs under this Rider may be subject to Pre-Certification and quantity
limits, as described below. Some drugs require Pre-Certification in order for them to be Covered
Services. These include, but are not limited to, medications that may require special medical
tests before use, or that are not recommended as a first-line treatment, or that have a potential
misuse or abuse. Drugs requiring Pre-Certification are identified within the Formulary with
“PA” next to the name of the drug.
Pre-Certification and Non-Participating Prescribing Providers. When You use a Non-
Participating Prescribing Provider, it is Your responsibility to contact the Plan before a
Prescription Order or Refill is filled to obtain any required Pre-Certification. If the Plan is not
contacted for Pre-Certification, You may be required to pay one hundred percent (100%) of the
cost for a Prescription Drug.
Specific Quantity Limits. You can get information on specific quantity limits from the searchable
Formulary on the website or by contacting the Customer Service Department. Before a
Prescription Order or Refill for a drug that exceeds the specific quantity limit can be filled, the Prescribing Provider must call the Plan. Retail Pharmacy. Prescription Drugs prescribed by a Prescribing Provider and obtained through a Pharmacy are Covered when You are eligible for Coverage under this Rider and You present Your identification card to a Pharmacy. The quantity of a Prescription Drug dispensed by a Pharmacy to fill a Prescription Order or Refill should not exceed that required for the lesser of: · The quantity prescribed in the Prescription Order or Prescription Refill; The amount determined to be Medically Necessary; or Depending on the form and packaging of the product, the following: The number of commercially prepackaged items (including but not limited to inhalers, topicals, and vials) needed for thirty-one (31) days of treatment with one copayment applied to each pre-packaged item or container. Mail Order Pharmacy. Prescription Drugs determined by the Plan to be Maintenance Medications on the Mail Order List and prescribed by a Prescribing Provider can be filled by the Mail Order Pharmacy. The quantity of a Prescription Drug will be dispensed pursuant to a ninety-three (93) day/cycle supply of approved Maintenance Medications. Specialty Pharmacy. Self-Administered Injectable Drugs are Covered under this Rider in the amounts described below when they are: · Ordered by a Prescribing Provider for use by a Member; Not limited or excluded elsewhere in this Rider; Self-Administered Injectable Drugs. Self-Administered Injectable Drugs are NOT available through the Mail Order Pharmacy program or at Participating retail Pharmacies. You shall pay the following to the Pharmacy, as applicable: · Ancillary Charges; and · One (1) Self-Administered Injectable Drug Copayment per Prescription Order or Refill.
The Copayment for Prescription Drugs at a Participating Pharmacy is:
· $10 for Formulary generic Prescription Drugs; or · $40 for Formulary brand name Prescription Drugs; or · $65 for non-Formulary Prescription Drugs. The Copayment for Prescription Drugs at a Non-Participating Pharmacy is: · $20 for Formulary generic Prescription Drugs; or · $80 for Formulary brand name Prescription Drugs; or · $130 for non-Formulary Prescription Drugs. The Copayment for Self-Administered Injectable Drugs at a Specialty Pharmacy is: · $10 for Formulary generic Prescription Drugs; or · $40 for Formulary brand name Prescription Drugs; or · $65 for non-Formulary Prescription Drugs. The Copayment for Self-Administered Injectable Drugs at a Non-Participating Pharmacy is: · $20 for Formulary generic Prescription Drugs; or · $80 for Formulary brand name Prescription Drugs; or · $130 for non-Formulary Prescription Drugs. The following also apply: · One (1) Copayment is due each time a prescription is filled or refilled up to a thirty-one (31) day supply. Insulin and diabetic supplies (insulin syringes, with or without needles, needles, blood and urine glucose test strips, lancets and devices, ketone test strips and tabs), up to a ninety-three (93) day supply, may be dispensed at three (3) times the applicable Copayment. Maintenance Drugs may be dispensed with three (3) Copayment(s) for a ninety-three (93) day supply. Only one drug and “Rx Unit” will be dispensed per prescription. The Rx Unit quantity is determined by FDA labeling, the dosage required or the Plan Formulary guidelines. Please note: One copayment is required for each Rx Unit, container, or prepackaged item. Oral contraceptives, up to a maximum of three (3) cycles may be dispensed at three times the applicable Copayment. The Ancillary charge described below does not apply to brand name contraceptives, as determined by the Plan. Select over-the-counter medications as determined by the Plan in an equivalent prescription dosage strength will be covered under this Rider for a Generic Copayment . Coverage of the selected over-the-counter medications requires a physician prescription. · Copayments and Ancillary Charges do not apply to the Out-of-Pocket Maximum listed on the
1. Authorized refills will not be provided after the lesser of:
i. twelve (12) months from the original date on the prescription order; or ii. the period of time limited by state or federal law. 2. Contraceptive diaphragms prescribed by a Prescribing Provider are limited to two (2) per year. 3. Coverage of injectable drugs is limited to Self-Administered Injectable Drugs as determined by the Plan and insulin, glucagon, bee sting kits, Imitrex and injectable contraceptives that are commonly and customarily administered by the Member. 4. Selected products with narrow therapeutic index, potential for misuse and/or abuse, high cost, or a narrow or limited range of Food and Drug Administration approved indications may require Pre-Certification by the Plan and may not be available through the mail order pharmacy program. 5. The Pharmacy shall not dispense a Prescription Drug order which, in the Pharmacist’s professional judgment, should not be filled. 6. To promote appropriate utilization, or following manufacturer’s recommendations, certain plan approved medications may have a quantity limit on the amount of medication dispensed. 7. The Plan reserves the right to include only one (1) Prescription Drug on its Formulary when the same Prescription Drug is made or sold under two or more different names. The Prescription Drug that is listed on the Formulary will be covered at the Formulary Copayment or Mail Order Copayment level. The Prescription Drug(s) that is/are not listed on the Formulary will not be covered. 8. Coverage of therapeutic devices or supplies requiring a Prescription Order and prescribed by a Prescribing Provider is limited to Plan approved devices, supplies, or spacers for metered dose inhalers. 9. Coverage through the Mail Order Pharmacy is not available on drugs that cannot be shipped by mail due to state or federal laws or regulations, or when the Plan considers shipment through the mail to be unsafe. Examples of these types of drugs include, but are not limited to, narcotics, amphetamines, DEA controlled substances or anticoagulants.

The following are Excluded from Coverage under this Rider:
1. Prescription Drugs related to the treatment of a Non-Covered Service (i.e. dental services).
2. Prescription Drugs that are not Medically Necessary. The Plan reserves the right to require
medical Pre-Certification for selected drugs before providing Coverage. 3. Prescription Drugs that are Experimental or Investigational, including those labeled “Caution- limited by Federal Law to Investigational Use,” FDA approved drugs used for investigational indications or at investigational doses and drugs found by the FDA to be ineffective or given as a part of a study. 4. Products not approved by the FDA, Prescription Drugs with no FDA approved indications, and DESI Drugs. This exclusion shall not apply to a drug, medicine or medication that is recognized for the treatment of cancer in one of the standard reference compendia or in substantially accepted peer-review medical literature. 5. Any Prescription Drug which is to be administered, in whole or in part, while You are in a hospital, medical office or other health care facility. 6. Compounded prescriptions are excluded unless all of the following apply: a. there is no suitable commercially-available alternative available; b. the main active ingredient is a Covered Prescription Drug; c. the purpose is solely to prepare a dose form that is Medically Necessary and is documented d. the claim is submitted electronically by the Pharmacy. 7. Vitamins and minerals (both over-the-counter and legend), except legend prenatal vitamins, and liquid or chewable legend pediatric vitamins as specified on the Formulary. 8. Injectable medications, except those designated by the Plan. 9. Drugs that do not require a prescription by federal or state law, that is, over-the-counter drugs or over-the-counter products, unless specifically designated for Coverage by the Plan or the Formulary list and obtained from the Pharmacy with a Prescription Order or Refill. Also excluded are Prescription Medications that have an over-the-counter equivalent or alternatives, unless otherwise specified on the Formulary. 10. Devices or supplies of any type, even though requiring a Prescription Order, such as but not limited to, therapeutic devices, support garments, corrective appliances, non-disposable hypodermic needles, syringes or other devices, regardless of their intended use, unless otherwise specified as a Covered benefit in this Rider. 11. Contraceptive implant systems, and prescription or nonprescription contraceptive devices (e.g., condoms, spermicidal agents, and Norplant). 12. Extemporaneous dosage forms of natural estrogen or progesterone; or any natural hormone replacement product, including but not limited to oral capsules, suppositories, creams and troches. 13. Anti-smoking medication or smoking cessation devices. 14. Prescription Drugs used to treat chemical dependency and/or substance abuse. 15. Drugs used primarily for hair restoration. 16. Pharmacological therapy for weight reduction, dietary supplements, appetite suppressants, and other drugs used to treat obesity, morbid obesity or assist in weight reduction. 17. Drugs, oral or injectable, used for the primary purpose of, or in connection with, treating infertility, fertilization, and/or artificial insemination. 18. Medications used for cosmetic purposes or to enhance athletic performance (i.e. anabolic steroids and minoxidil lotion, retin A (tretinoin) for aging skin). Also excluded are drugs, oral or injectable, used to slow or reverse normal aging processes (i.e. growth hormone, testosterone, etc.). 19. Prescription Drugs dispensed in unit doses, when bulk packaging is available, or repackaged 20. Replacement for lost, destroyed or stolen prescriptions. 21. Duplicate drug therapy (i.e. two antihistamine drugs). 22. Oral dental preparations and fluoride rinses, except pediatric fluoride tablets or drops as 23. Prescriptions that You are entitled to receive without charge under any Workers’ Compensation law, occupational statute, or any law, or regulation of similar purpose.
1. The Plan and its designees shall have the right to release any and all records concerning health care services that are necessary to implement and administer the terms of this Rider or for appropriate medical/pharmaceutical review or quality assessment. 2. The Plan shall not be liable for any claim, injury, demand or judgment based on tort or other grounds (including warranty of drugs) arising out of or in connection with the sale, compounding, dispensing, manufacturing, or use of any Prescription Drug whether or not Covered under this Rider.

1. Your Coverage under this Rider will end when Coverage under the COC ends.
2. Nothing herein shall be held to vary, alter, waive, or extend any of the definitions, terms,
conditions, provisions, agreements or limitations of the COC, other than as stated above. 3. The Plan utilizes Prescription Drug rebates as a mechanism to reduce Prescription Drug

Source: http://www.allegiantnet.info/resources/Rx.pdf

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