Covered expenses under the Rx Program include fees under the TrueScripts' Pharmacy Services Agreement. LIMITS AND EXCLUSIONS The Rx Program’s prescription drug benefits apply only when a Participant incurs a covered prescription drug charge. The covered drug charge for any one prescription will be limited to: 1. Refills only up to the number of times specified by a prescriber. 2. Refills up to one year from the date of order by a prescriber. In addition to exclusions in the Medical Component Plan document, the following exclusions apply. One or more exclusions may apply to any prescription. When exclusions apply to only certain prescription drugs, you can call TrueScripts at (844) 257-1955 for information about which prescription drugs are excluded. Excluded medications include: 1. Medications for any condition, injury, sickness, or mental health disorder arising out of, or in the course of, employment for which benefits are available under any workers' compensation law or other similar laws, whether or not a claim for such benefits is made or payment or benefits are received under any workers' compensation law or other similar laws. 2. Any prescription drug for which payment or benefits are covered or available as primary from the local, state, or federal government (for example Medicare), whether or not payment or benefits are received, except as otherwise provided by law. 3. Medications available over the counter that do not require a prescription order or refill by federal or state law before being dispensed, unless the plan has designated over-the-counter medication as eligible for coverage as if it were a prescription drug and it is obtained with a prescription order or refill from a prescriber. 4. Compounded drugs that do not contain at least one ingredient that has been approved by the U.S. Food and Drug Administration and requires a prescription order or refill. 5. Compounded drugs that are available as a similar commercially available prescription drug. 6. Medications dispensed outside of the United States, except in an emergency and except for International Importation Medications as approved for by the Plan. 7. Durable medical equipment (prescribed and non-prescribed outpatient supplies, other than the diabetic supplies and inhaler spacers specifically stated as covered in the Schedule of Benefits). 8. The amount dispensed (days’ supply or quantity limit) which exceeds the applicable supply limit. 9. The amount dispensed (days’ supply or quantity limit) which is less than the minimum supply limit. 10. Certain new drugs and/or new dosages, until they are reviewed and assigned to a tier by the TrueScripts P & T Management Committee, a list of which may be obtained by calling TrueScripts at (844) 257-1955. 11. Medications prescribed, dispensed, or intended for use during an inpatient stay. 12. Prescription drugs, including new prescription drugs or new dosage forms, that do not meet the definition of a covered expense. Huntington County Community Schools Prescription Benefits Program SPD January 1, 2025 Page 9 of 15