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This Plan will provide Prescription Drug benefits (as stated in the Schedule of Benefits “Oral Chemotherapy Drugs with IV Equivalents”) for the seven chemo agents available in both oral and IV form. The seven oral chemo drugs with IV equivalents are:

Brand Name Generic Name

Alkeran MELPHALAN Cytoxan CYCLOPHOSPHAMIDE Myleran BUSULFAN Temodar TEMOZOLOMIDE Hycamtin Topotecan Oforta FLUDARABINE VePesid ETOPOSIDE

Benefits are unchanged for all other oral chemo drugs. LIMITATIONS & EXCLUSIONS

The following limitations and exclusions apply to the Plan:

(a) A pharmacy shall not dispense a Prescription Order or Refill which, in the pharmacist's professional judgment, should not be filled.

(b) Authorized Refills will be provided for the lesser of:

1. twelve (12) months from the original date on the Prescription Order or Refill unless limited by state or federal law; or

2. the number of Refills indicated by the Prescriber.

(c) Some medications are subject to quantity limits. Specific Quantity Limits can be obtained through the Customer Service Department and by searching the online Prescription Drug Formulary.

(d) Coverage of injectable drugs is limited to Self-Administered Injectable Drugs and injectable diabetes agents, bee sting kits, injectable migraine agents and injectable contraceptives that are commonly and customarily administered by the Covered Person.

(e) Self-Administered Injectable Drugs and Specialty Medications are available at retail for two fills then must be obtain from the Specialty Pharmacy.

(f) The Claims Administrator reserves the right to include only one manufacturer’s product on the Formulary when the same or similar drug (that is, a drug with the same active ingredient), supply or equipment is made by two or more different manufacturers. The product that is listed on the Formulary will be covered at the applicable benefit. The product or products not listed on the Formulary will be excluded from coverage.

(g) The Claims Administrator reserves the right to include only one dosage or form of a drug on the Formulary when the same drug (that is, a drug with the same active ingredient) is available in different dosages or forms (for example, but not limited to, dissolvable tablets, capsules, etc.) from the same or different manufacturers. The product in the dosage or form that is listed on the Formulary will be covered at the applicable benefit. The product or products in other forms or dosages that are not listed on the Formulary will be excluded from coverage.

(h) Coverage of therapeutic devices or supplies requiring a Prescription Order or Refill and prescribed by a Prescriber is limited to Plan-approved diabetic test strips and lancets and contraceptive diaphragms.

(i) Plan-approved blood glucose meters, asthma holding chambers and peak flow meters are Covered Charges, but are limited to one (1) Prescription Order per Benefit Year.

(j) Unless this Summary Plan Description (SPD) indicates that Preauthorization is not required, Preauthorization is required for selected products with a Narrow Therapeutic Index, potential for misuse and/or abuse, and a narrow or limited range of FDA-approved indications. These products may not be available from the Mail Order Pharmacy. Information about which drugs require Preauthorization can be obtained through the Customer Service Department or the Claims Administrator’s searchable Formulary on the website.

(k) Contraceptive diaphragms, oral contraceptives and time-released injectable contraceptives, including but not limited to birth control pills, are Covered Charges unless specifically excluded as described by the Plan.

(l) The Claims Administrator reserves the right to limit the location at which a Covered Person can fill a covered Prescription Order or Refill to a pharmacy that is mutually agreeable to both the Claims Administrator and the Covered Person. Such limitation may be enforced in the event that the Claims Administrator identifies an unusual pattern of Claims for Covered Charges.

(m) Certain vaccines are covered when obtained and administered in a pharmacy by a certified immunizing pharmacist and billed through the online Claims adjudication system.

The following are not Covered Charges under the Plan:

(a) Any Prescription Drugs, injectables, supplies, devices or other items covered under the Medical Benefits.

(b) Prescription Drugs dispensed by Non-Participating Pharmacies, except as described by the Plan. (c) Devices or supplies of any type, even though requiring a Prescription Order unless otherwise

specified as a Covered Charge. These include, but are not limited to: therapeutic devices, support garments, corrective appliances, non-disposable hypodermic needles, or other devices, regardless of their intended use.

(d) Drugs prescribed and administered in the Physician's office, or during or as part of an Inpatient or ambulatory surgery procedure or admission.

(e) Implantable time-released medication (e.g., Eligard, Zoladex).

(f) Drugs which do not require a Prescription by federal or state law, unless specifically designated for coverage by the Claims Administrator. For example, but not limited to: Over-the-Counter drugs or Over-the-Counter equivalents, behind-the-counter drugs, nutraceuticals, medical foods (except when coverage is required by law), and dietary supplements.

(g) Drugs, oral or injectable, used for the primary purpose of, or in connection with, treating Infertility, fertilization and/or artificial insemination, unless coverage is specifically listed in the Schedule of Benefits.

(h) Experimental or Investigational drugs.

(j) Vitamins and minerals, both Over-the-Counter and Legend, except Legend prenatal vitamins for pregnant or nursing females, liquid or chewable Legend pediatric vitamins for Children under age thirteen (13), and potassium supplements to prevent/treat low potassium.

(k) Oral dental preparations and fluoride rinses, except fluoride tablets or drops.

(l) Refill Prescriptions resulting from loss or theft, unless authorized by Plan Administrator for one refill. (m) Growth hormones and insulin-like growth hormone factor-1, when not Medically Necessary to treat

an Illness or Injury.

(n) Pharmacological therapy for weight reduction.

(o) Prescriptions for which the Covered Person is entitled to receive coverage without charge under any Workers' Compensation Law, or occupational disease statute, or any law or regulation.

(p) Prescriptions directly related to non-Covered Charges, as further described in the Medical Benefits section of the Plan Document.

(q) Medications to prevent infections related to foreign travel are excluded from coverage. Drugs prescribed for the purpose of facilitating travel, including but not limited to medications, devices and supplies for motion Illness (e.g. Relief Bands).

(r) Medications used for the treatment or ongoing maintenance care of non-congenital transsexualism, gender dysphoria, or sexual reassignment or change.

(s) Medications used for travel prophylaxis. GENERAL PROVISIONS

Each Covered Person authorizes and directs any pharmacy that filled a Prescription Order or Refill covered under this Plan to make available to the Plan information relating to all Prescription Orders or Refills, copies thereof and other records as needed by the Plan to implement and administer the terms of this Plan, conduct appropriate quality review or investigate possible Substance Abuse or criminal activity. Each Covered Person, by accepting coverage under this Plan, agrees that the Plan and any of its designees shall have the right to release any and all records concerning health care services which are necessary to implement and administer the terms of this Plan, conduct appropriate quality review or investigate possible Substance Abuse or criminal activity.

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 or insulin whether or not covered under this Plan.

Coverage under this Plan shall terminate when a Covered Person’s coverage under the Plan ends.

Nothing contained herein shall be held to vary, alter, waive, or extend any of the terms, conditions, provisions, agreements, or limitations of the Plan other than as stated above.