Benefit Limitations Clause Samples

Benefit Limitations. This benefit has one or more exclusions as specified in the Exclusions Section. You have the option to purchase up to a 90-day supply of Prescription Drugs/Medications. Under the up to a 90-day at Retail Pharmacy benefit, Preferred Generic, Non-Preferred Generic, Preferred Brand and Non-Preferred Drugs can be obtained from an In-network Pharmacy. If you choose the 90-days at retail option, you will be charged one Copayment per 30-day supply up to a maximum of a 90-day supply. You will be charged three applicable Copayments for up to a 90-day supply up to the maximum dosing recommended by the manufacturer/FDA. Some medications may qualify for third-party copayment assistance programs which could lower your out-of-pocket costs for those products. For any such medication where third-party copayment assistance is used (Discount Cards or Prescription Drug Savings Cards), the Member shall not receive credit towards their maximum out-of-pocket or deductible for any copayment or coinsurance amounts that are applied to a manufacturer coupon or rebate. Self-Administered Specialty Pharmaceuticals are self-administered, meaning they are administered by the patient, a family member or caregiver. Specialty Pharmaceuticals are often used to treat complex chronic, rare diseases and/or life- threatening conditions. Most Specialty Pharmaceuticals require Prior Authorization and must be obtained through the specialty pharmacy network. Specialty Pharmaceuticals are often high costs, typically greater than $600 for up to a 30-day supply. Specialty Pharmaceuticals are not available through the retail or mail order option and are limited to a 30-day supply. Certain Specialty Pharmaceuticals are limited to an initial fill up to a 15-day supply to ensure patients can tolerate the new medication. For a complete list of these drugs, please see the Specialty Pharmaceutical listing at ▇▇▇▇://▇▇▇▇.▇▇▇.▇▇▇/idc/groups/public/documents/communication/pel_▇▇▇▇▇▇▇▇.pdf. You can contact our Presbyterian Customer Service Center at (▇▇▇) ▇▇▇-▇▇▇▇ or ▇-▇▇▇-▇▇▇-▇▇▇▇, Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711

Benefit Limitations. Your Covered Benefits may have specific limitations or requirements and are listed under the specific benefit section of this document: • Some Benefits may be subject to dollar amount and/or visit limitations. • Benefits may be excluded if the services are provided by Out-of-network Practitioners/Providers. • Some Benefits may be subject to Prior Authorization. Refer to your Summary of Benefits and Coverage and the Benefits Section for details about these limitations. In the event of any major disaster, epidemic or other circumstances beyond our control, we shall render or attempt to arrange Covered Benefits with In-network Practitioners/Providers insofar as practical, according to our best judgment, and within the limitations of facilities and personnel as are then available. However, no liability or obligation shall result from nor shall be incurred for the delay or failure to provide any such service due to the lack of available facilities or personnel if such lack is the result of such disaster, epidemic or other circumstances beyond our control, and if we have made a good-faith effort to provide or arrange for the provision of such services. Such circumstances include complete or partial disruption of facilities, war, act(s) of terrorism, riot, civil insurrection, disability of a significant part of a Hospital, our personnel or In-network Practitioners/Providers or similar causes. This provision does not impose any limitation on the availability of Coverage for services provided by Out-of-network Practitioners/Providers. If you are Covered by our continuation policy and are also Covered by another group medical plan you shall receive our benefits to the extent that we are the secondary payer of all eligible charges, subject to the terms, conditions and limitations of this Agreement.

Benefit Limitations. Full-time regular employees shall be entitled to all benefits of this Agreement except as limited during the probationary period. During the probationary period full-time regular employees shall not be eligible for coverage under the Dental Plan and the Long Term Disability Plan, but shall receive coverage under the B.C. Medical Plan, the Extended Health Benefits Plan and the Group Insurance Plan. Upon completion of the probationary period, a full-time regular employee will be credited with service back to the date of hire for the purpose of determining all the benefits under this Agreement. Except as provided for in 6.04(a) ii), by agreement with the Union the Corporation may hire a temporary employee to fill a full-time regular position as defined above. A full-time temporary employee who is successful in securing a regular position while a temporary employee shall have the term of employment since her/his last date of hire as a temporary employee applied towards the waiting periods for all welfare benefit plans. Those who have served the required waiting periods will be immediately eligible for coverage under those welfare benefit plans provided to full-time regular employees.

Benefit Limitations. Unless otherwise specifically agreed by the Union, part-time temporary employees will be paid an hourly rate which will be 108% of the hourly rate which is at the mid-point of the salary range for the appropriate classification. The enhanced rate shall be in lieu of all other benefits except that any benefit required by law will be in addition to the enhanced rate. Part-time temporary employees will receive 10.8% of gross earnings at termination in lieu of holiday pay as set out in Article 16 and in lieu of vacation entitlements.

Benefit Limitations i) will conclude their probationary periods after having worked the equivalent hours as described for the probationary period. ii) will be credited with seniority and service back to date of hire upon completion of the probationary period, and such credit during that period and henceforth shall be in accordance with the hours worked for the Corporation provided the employee retains membership in the Union for that period. iii) will be laid off in accordance with the principle of inverse seniority within their department. iv) will be entitled to coverage under the Dental Plan, Long Term Disability Plan, group life insurance plan, B.C. medical services plan and Extended Health Benefits Plan on a cost share basis in accordance with hours worked. The percentage of premiums paid by the employee will be determined, based on the rolling average of the percentage of full-time hours worked over the previous six pay periods. The welfare benefit provisions set out above will apply to all newly hired part-time regular employees, and existing employees securing a part-time regular position. Existing part-time regular employees, as at August 25, 1992, and who continue as part-time regular employees, have the option of enrolling in the welfare benefit programs, thereby discontinuing receipt of the 8% paid in lieu of benefits, or declining enrolment and continuing to receive the 8% in lieu of these benefits. v) will be entitled to receive sick leave on a pro-rata basis to cover scheduled days of work. vi) will be remunerated for statutory holidays, as set out in Article 16.01, at the rate of 4.4% (4.8% effective January 1, 2013) of gross earnings, and shall receive 2% of gross earnings for each week of earned vacation entitlement, as provided for in Article 15.03, during each calendar year. A part-time regular employee who wishes to take vacation upon completion of the service requirements may request the applicable percentage of earnings to date, subject to a maximum of 2 such requests in a calendar year. The amount paid out in such instances will be deducted in the calculation of vacation and holiday pay at year-end. The above compensation represents the part-time employees' total claim for vacation and holiday pay, except that at the discretion of the Corporation such employees may be paid for holidays as they occur provided such is deducted from total compensation above. vii) may be terminated in accordance with this Agreement, except that pay in lieu of any notice sh...

Benefit Limitations. Full-time temporary employees shall be entitled to all the benefits of this Agreement, except that full-time temporary employees: i) will be governed by Article 6.01 during their probationary period. ii) will not have any rights under the layoff and recall provisions of Article 8. However, the Corporation will advise such employees of a pending layoff as early as possible. iii) will not have any rights under technological or procedural change. iv) will be paid 10.8% of gross earnings with each pay period in lieu of annual vacation and general holiday leave. v) will not be entitled to coverage under the Dental Plan, Long Term Disability Plan, Group Life Insurance Plan, B.C. Medical Services plan, or Extended Health Benefits Plan. In lieu thereof, full-time temporary employees will be paid at the rate of 108% of the rate they would have otherwise attained. vi) will be entitled to benefits under the short term disability plan upon the completion of her/his probationary period in accordance with Article 17.03. vii) can apply for other bargaining unit positions and receive selection preference in accordance with Article 7.03(c) after completion of the probationary period. If selected, the Corporation may require the temporary employee to fulfil her/his temporary assignment before commencing her/his new position.

Benefit Limitations. In accordance with Article 4.03, the employee i) shall not attain seniority until completion of the probationary period.

Benefit Limitations. In no event will the total of benefit payments exceed the Plan Maximum.

Benefit Limitations. Probationary employees are not eligible for the Group Insurance Plan.