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| The following drugs will NOT be Tiered properly in the Partners Rx website. If Exclusions or Additions are listed in the white boxes below, the drugs are classified
as unique to your plan. |  |
| Exclusions:The following drugs have been EXCLUDED from your Pharmacy Plan and are NON-FORMULARY. You may purchase these drugs with your HSA funds, but the cost WILL NOT be reimbursed once you meet your deductible, nor will it count toward your deductible.
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| Additions:The following drugs have been ADDED to your Pharmacy Plan and are FORMULARY. The cost will count toward your deductible and if you are over your deductible, the cost will be reimbursed 100%.
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