 FDA approved prescription and over-the-counter contraceptive drugs and devices including injectable contraceptives and internally implanted time-release contraceptive drugs, emergency contraceptives, spermicide, and contraceptive devices such as condoms, intrauterine devices, diaphragms, and cervical caps.  Glucagon emergency kits, insulin, ketone test strips for urine-testing, blood glucose test strips, and disposable needles and syringes when prescribed for the treatment of diabetes. We cover additional diabetic equipment and supplies, including lancets and injection aids, under the “Durable Medical Equipment (DME) and External Prosthetic Devices and Orthotic Devices” section.  Self-administered chemotherapy medications used for the treatment of cancer.  Post-surgical immunosuppressive drugs after covered transplant Services.  Prescription medications purchased in a foreign country when associated with an Emergency Medical Condition. Cost Share for Covered Drugs and Supplies When you get a prescription from a Participating Pharmacy, or order a prescription from our Mail-Order Pharmacy, you pay the Cost Share as shown in the “Benefit Summary.” This applies for each prescription consisting of up to the day supply shown in the “Benefit Summary.” Outpatient prescription drugs and supplies are subject to the applicable Cost Share until the medical Out-of-Pocket Maximum is met. If Charges for the drug or supply are less than your Cost Share, you pay the lesser amount. When you obtain your prescription through a pharmacy owned and operated by Kaiser Permanente (including our Mail-Order Pharmacy) you may be able to use an approved drug manufacturer coupon as payment for your prescription Copayment or Coinsurance, after you satisfy your Plan’s Deductible. Drug manufacturer coupons cannot be used toward payment of the Deductible in this HSA-compatible high deductible health Plan. If the coupon does not cover the entire amount of your Copayment or Coinsurance, you are responsible for the additional amount up to the applicable Copayment or Coinsurance as shown in the “Benefit Summary.” When you use an approved coupon for payment of your Copayment or Coinsurance, the coupon amount will count toward the Out-of-Pocket Maximum. For more information about the Kaiser Permanente coupon program rules and limitations, please call Member Services, or go to kp.org/rxcoupons. Day Supply Limit The prescribing provider determines how much of a drug or supply to prescribe. For purposes of day supply coverage limits, the prescribing provider determines the amount of a drug or supply that constitutes a Medically Necessary 30-day (or any other number of days) supply for you. When you pay the Cost Share shown in the “Benefit Summary,” you will receive the prescribed supply up to the day supply limit. If you wish to receive more than the covered day supply limit, then you must pay for any prescribed quantity that exceeds the day supply limit, unless due to medication synchronization, in which case we will adjust the applicable Cost Share for the quantity that exceeds the day supply limit. You may receive a 12-month supply of a contraceptive drug at one time, unless you request a smaller supply or the prescribing provider determines that you must receive a smaller supply. We may limit the covered refill amount in the last quarter of the Year if we have previously covered a 12-month supply of the contraceptive drug within the same Year. EWCLGHDHP1983ACT0124 59 WAPEBB-CD-ACT