Catastrophic Clause Samples

Catastrophic. The System or a main subsystem is unavailable, preventing the System or a core function from operating or causing core functions or major functionality to operate with grossly incorrect results, such as material data processing errors. There is no workaround.

Catastrophic. If You selected catastrophic coverage, You must meet one of the following: • Be under the age of 30 on the first day of the Policy Year; or • Have received a certificate of exemption because of hardship or lack of affordable coverage

Catastrophic. The System or a main subsystem is unavailable, preventing the System or a core function from operating or causing core functions or major functionality to operate with grossly incorrect results, such as material data processing errors. There is no workaround. All System users are unable to register as volunteers or for events, access their event certification records or instructor history.

Catastrophic. When a member's True Out-of-Pocket (TrOOP) cost reaches $5,100.

Catastrophic a. All high tech, high cost therapies require prior approval and in some instances special procedures which remove these claims from the normal adjudication process. For example, Protropin is a costly growth hormone which is used to stimulate growth in children diagnosed with dwarfism. NATIONAL's prior approval process requires the member, or the pharmacy provider, to contact NATIONAL before the medication is dispensed. NATIONAL Health Card's Manager of Claims Administration or a designated member of the Health Services Department for our Managed Care Clients must provide approval and an authorization code before the medication is dispensed. For this particular medication, the same procedure is followed with each refill. b. Similar procedures are in place for home infusion therapy. Because infusion therapy providers are required to contact NATIONAL when beginning therapy, we are often able to negotiate significant additional discounts with the provider and request that they accept our negotiated discount as payment in full. Since people requiring this type of treatment are often very ill, we are able to relieve them of some financial concerns while saving the client money. c. For other drug therapies which are costly but do not require constant monitoring, NATIONAL keep's a doctor's certification letter on file and the local pharmacist calls before dispensing the medication. NATIONAL provides an override code enabling the pharmacist to transmit the claim via standard electronic transmission. NATIONAL is currently developing the capability of indicating overrides on a member's record so that pharmacists will not have to call for override codes on refills. However, there will always be those therapies that NATIONAL may wish to keep out of mains of electronic transmission due to cost, limited providers and the limited duration of therapy, and/or the careful monitoring that is required. Law No. 98-IS-002 Rev. 3/4/98 National Medical Health Card/Prescription Drug/EMHP d. Because of NATIONAL's reputation as a forward thinking company, it is often notified as new high tech drug therapies such as Pulmozyne and Beta Seron come to market. Often these drugs are in short supply but NATIONAL establishes a procedure either with the manufacturer or the distributor that enables it's subscribers to obtain the necessary medication easily while allowing NATIONAL to monitor the cost and duration of therapy. NATIONAL is currently working with Berlex to ensure that NATIONAL's m...

Catastrophic. When a member's True Out-of-Pocket (TrOOP) cost reaches $5,100. When a member purchases a drug at an out-of-network pharmacy in an emergency situation: a. the member will pay the same coinsurance as would have applied at a network pharmacy, but at the out-of-network pharmacy price, and/or, b. the member will pay the same copayment as would have applied at a network pharmacy, plus the difference between the out-of-network pharmacy price and the network pharmacy price, not to include maximums. Tier 1* Tier 2 Tier 3 Tier 4 037/TBD2 PDP TBD $15 $75 $180 N/A Greater of $3.40 for generic/multiple source drugs ($8.50 for all others) or 5% coinsurance ($15 Maximum out-of-pocket per perscription) $5,100 Plan/Option PDP Option Number 90 Day Standard Mail Order (2) from $0 to Catastrophic 90 Day Standard Mail Order Cost Sharing from Catastrophic to Unlimited Out-of-Pocket that triggers Catastrophic Tier 1* Tier 2 Tier 3 Tier 4 037/TBD2 PDP TBD $12.50 $62.50 $150 N/A Greater of $3.40 for generic/multiple source drugs ($8.50 for all others) or 5% coinsurance ($12.50 Maximum out-of-pocket per perscription) $5,100 *Tier 1: Generic or Preferred Generic - Generic or brand drugs that are available at the lowest cost share for this plan. Tier 2: Preferred Brand - Generic or brand drugs that Humana offers at a lower cost than Tier 3 Non-Preferred Drug. Tier 3: Non-Preferred Drug - Generic or brand drugs that Humana offered at a higher cost than Tier 2 Preferred Brand drugs. Tier 4: Specialty Tier - Some injectables and other higher-cost drugs.