The portion of a covered expense that is actually paid by the Participant will apply towards deductibles and coinsurance under Medical Component Plan only if you enroll in the Integrated Medical Component Plan. Deductibles, coinsurance, and co-pays apply towards applicable out of pocket limits. SPECIALTY PHARMACY SCHEDULE OF BENEFITS PER PERSON “Specialty Drug” means a drug, biologic, or biosimilar that typically has more than one of the following key characteristics. 1. A drug, biologic, or biosimilar that treats a medical condition with complex biology which is often difficult to diagnose, requires frequent dosing adjustments, and intensive clinical monitoring to decrease drug toxicity and increase the probability for beneficial treatment outcomes. 2. A drug, biologic, or biosimilar that treats a medical condition that if left untreated would be progressive, enduring, debilitating, and potentially life threatening. 3. A drug, biologic, or biosimilar with an FDA designated orphan drug status. 4. A drug, biologic, or biosimilar approved by the FDA and has been determined that a Risk Evaluation and Mitigation Strategies (REMS) program is necessary for monitoring of medications with a high potential for serious adverse effects and assure safe and effective use. 5. A drug, biologic, or biosimilar approved for use by the FDA through the Emergency Use Authorization (EUA) process. 6. A drug, biologic, or biosimilar administered by a healthcare professional or healthcare setting such as an inpatient or infusion centers. 7. A drug, biologic, or biosimilar that has unique shipment, storage, or other special handling requirements. 8. A drug, biologic, or biosimilar supplied by a limited distribution drug pharmacy network dispensed directly to the patient or healthcare setting and not available through a retail pharmacy. 9. A drug, biologic, or biosimilar requiring individualized care, regardless of dosage form or route of administration, to assist, educate, monitor, and provide appropriate compliance behavior (e.g., persistence and adherence) to facilitate therapeutic goals. 10. A drug, biologic, or biosimilar with a high-cost level of care, defined as a claim greater than $1,500 per fill. Note: If a drug, biologic, or biosimilar therapeutic equivalent or biosimilar product becomes available for a brand specialty drug, then the equivalent drug, biologic, or biosimilar will be included in the Specialty Drug list. If the Plan covers Specialty Drugs, a prior authorization is required for all Specialty Drugs, a list of which can be obtained by calling TrueScripts at (844) 257-1955. First time dispensing of a Specialty Drug may be limited to less than a 30-day supply when not prepackaged for a larger quantity. Additionally, a maximum unit of measure quantity limit per person/plan year may apply to some Specialty Drugs. Covered prescription injectable(s) and certain other specialty drugs such as chemotherapies may only be available through a designated specialty pharmacy. Specialty Drugs are categorized into the above Copay Tiers under Schedule of Huntington County Community Schools Prescription Benefits Program SPD January 1, 2025 Page 6 of 15