112 Dependent A member of the Subscriber’s family who meets the rules listed in the “Please refer to the “Prescription Drug List” and “Step Therapy Protocol Exceptions” sections in “Prescription Drug Benefit at a Home Delivery (Mail Order) Pharmacy” for the process to submit an exception request for Drugs not on the Prescription Drug List or that require Step Therapy.

2025 Retiree Indemnity Plan Booklet - Page 113 2025 Retiree Indemnity Plan Booklet Page 112 Page 114