outpatient drug as an “emergency supply.” Such emergency supply must be obtained in accordance with the Rx Program. PREVENTIVE CARE SCHEDULE OF BENEFITS PER PERSON PER CALENDAR YEAR The Plan routinely covers exams and screenings that prevent and identify early certain medical conditions. In accordance with the Affordable Care Act, the Rx Program covers services for preventive care at 100%. Contraceptive Preventive Care The Rx Program will cover certain contraceptive preventive care prescriptions or devices for women without cost sharing. Coverage without cost sharing means women can receive the prescriptions or devices without having to pay a deductible, coinsurance, or copayment. There are some contraceptive prescriptions for which Participants will have to pay a deductible, copayment, or coinsurance. To minimize your out-of-pocket pharmacy costs, follow the below guidelines for prescriptions that will be covered with no cost sharing. The Rx Program benefits cover female contraceptive prescriptions with no cost sharing for Participants receiving these drugs or devices for the prevention of pregnancy that are: 1. Prescribed by a prescriber; 2. Generic; 3. Brand-name drugs without a generic or therapeutic equivalent; and 4. Obtained from an in-network pharmacy. The Rx Program will also cover brand name drugs where a generic is available with no cost sharing if approved thru the TrueScripts Prior Authorization process. Contraceptives not included in the above will be covered at the applicable Participant’s cost share. Additional Preventive Care Additional preventive prescription drug benefits covered according to the Affordable Care Act include the following if: 1. Prescribed by a licensed prescriber; 2. Are generic; 3. Are brand-name drugs without a generic equivalent; and 4. Are obtained from an in-network pharmacy. Aspirin Quantity Limit: 1/day Aspirin products up to 325mg All prescription products, Age limit 45-75 years of including OTCs if processed Clenpiq, Gavilyte-C, Gialax Bowel prep medications age as a prescription. Brand Kit, PEG 3350, Peg-Prep, name will be covered only Plenvu, Suflave, Sutab. if it doesn't have a generic. Huntington County Community Schools Prescription Benefits Program SPD January 1, 2025 Page 12 of 15