Outpatient Prescription Drug Rider Kaiser Permanente Senior Advantage ( HMO) This rider is part of the Kaiser Permanente Senior Advantage (HMO) Evidence of Coverage (EOC) to which it is attached. All provisions of this rider become part of the EOC "Chapter 4: Medical Benefits Chart (what is covered and what you pay)" section. This entire benefit rider is therefore subject to all the terms and provisions of the EOC. Note: We also cover some outpatient drugs as listed in the Medical Benefits Chart "Medicare Part B prescription drugs" section. Covered drugs and supplies We cover outpatient prescription drugs and supplies as described in this "Outpatient Prescription Drug Rider." Covered drugs and supplies must be prescribed by a network provider or any licensed dentist in accordance with our drug formulary guidelines. Over-the-counter contraceptive drugs, devices, and products, approved by the FDA, do not require a prescription i n order to be covered. You must obtain drugs and supplies at a network pharmacy (including our mail-order pharmacy) or in a prepackaged take-home supply from a network facility or network medical office. Cost-sharing for covered drugs and supplies When you get a prescription from a network pharmacy, network facility or network medical office, or order a prescription through our mail-order pharmacy, you pa y the applicable cost- sharing listed in the Medical Benefits Chart "Prescription drugs" section. T his applies for each prescription consisting of up to the day supply listed in the Medical Benefits Chart. If plan charges for the drug or supply are less than your copayment or coinsurance, you pay the lesser amount. 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 applicable cost-sharing listed in the Medical Benefits Chart, 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 plan charges for any prescribed quantity that exceeds the day supply limit. Medication synchronization Medication synchronization is the coordination of medication refills, if you are taking two or more medications for a chronic condition, so that your medications are refilled on the same schedule. You may request medication synchronization for a new prescription from the prescribing provider or a network pharmacy who will determine the appropriateness of medication synchronization for the drugs being dispensed and inform you of the decision. RSARX0124 1