How Copayment Amounts Apply Clause Samples
How Copayment Amounts Apply. If the Allowable Amount of the drug is less than the Copayment, You pay the lower cost. When that lower cost is more than the amount You would pay if You purchased the drug without using Your HMO pharmacy benefits or any other source of drug benefits or discounts, You pay such purchase price. You will pay no more than the applicable Brand Name Drug Copayment if the prescription has no generic equivalent. If You receive a Brand Name Drug when a generic equivalent is available, the Copayment will be the total of the Generic Drug Copayment plus the difference between the cost of the Generic Drug equivalent and the cost of the Brand Name Drug Exceptions to this may be allowed for certain preventive medications (including prescription contraceptive medications) if Your Health Care Practitioner submits a request to HMO indicating that the Generic Drug would be medically inappropriate, along with supporting documentation. If HMO grants the exception request, any difference between the Allowable Amount for the Brand Name Drug and the Generic Drug equivalent will be waived. How Member Payment is Determined. Prescription drug products are separated into tiers. Generally, each drug is placed into one of six drug tiers: About Your Benefits Covered Drug List. Drugs listed on the Drug List are selected by HMO based upon the recommendations of a committee, which is made up of current and previously practicing Physicians and pharmacists from across the country, some of whom are employed by or affiliated with HMO. The committee considers existing drugs approved by the FDA, as well as those newly FDA approved for inclusion on the Drug List. Entire drug classes are also regularly reviewed. Some of the factors committee members evaluate include each drug’s safety, effectiveness, cost and how it compares with drugs currently on the Drug List.
How Copayment Amounts Apply. If the Allowable Amount of the Drug is less than the Copayment, You pay the lower cost. You will pay no more than the applicable Preferred Brand Name Drug or Non- Preferred Brand Name Drug Copayment if the prescription has no generic equivalent. If You receive a Brand Name Drug when a generic equivalent is available, the Copayment will be the total of the Generic Drug Copayment plus the difference between the cost of the Generic Drug equivalent and the cost of the Brand Name Drug. Drug Coupons, Rebates and Other Discounts. Drug manufacturers may offer drug coupons, rebates or other drug discounts to Members, which may impact the benefits provided under this Certificate. The total benefits payable will not exceed the balance of the Allowable Amount remaining after all drug coupons, rebates or other drug discounts have been applied. The Member agrees to reimburse HMO any excess amounts for benefits we have paid You and for which You are not eligible due to the application of drug coupons, rebates or other drug discounts. About Your Benefits
How Copayment Amounts Apply. When Your Physician has marked the Prescription Order “Brand Necessary,” the pharmacist may only dispense the brand name drug and You pay the appropriate Brand Name Copayment Amount. ▪ If the Physician has not stipulated Brand Necessary, You may still choose to buy the brand name drug instead of the Generic Drug. If the brand name drug dispensed is on the Preferred Brand Name Drug List, You will pay the Preferred Brand Name Drug Copayment Amount plus the difference between the Generic Drug and the Preferred Brand Name Drug. ▪ If the brand name drug is a Non-Preferred Brand Name Drug, You pay the Non-Preferred Brand Name Drug Copayment Amount.
How Copayment Amounts Apply. If the Allowable Amount of the Drug is less than the Copayment, You pay the lower cost. You will pay no more than the applicable Preferred Brand Name Drug or Non- Preferred Brand Name Drug Copayment if the prescription has no generic equivalent. If You receive a Brand Name Drug when a generic equivalent is available, the Copayment will be the total of the Generic Drug Copayment plus the difference between the cost of the Generic Drug equivalent and the cost of the Brand Name Drug. Drug Coupons, Rebates and Other Discounts. Drug manufacturers may offer drug coupons, rebates or other drug discounts to Members, which may impact the benefits provided under this Certificate. The total About Your Benefits
How Copayment Amounts Apply. If the Allowable Amount of the drug is less than the Copayment, You pay the lower cost. When that lower cost is more than the amount You would pay if You purchased the drug without using Your HMO pharmacy benefits or any other source of drug benefits or discounts, You pay such purchase price. You How Member Payment is Determined. Prescription drug products are separated into tiers. Generally, each drug is placed into one of six drug tiers:
How Copayment Amounts Apply. If the Allowable Amount of the drug is less than the Copayment, You pay the lower cost. When that lower cost is more than the amount You would pay if You purchased the drug without using Your HMO pharmacy benefits or any other source of drug benefits or discounts, You pay such purchase price. You will pay no more than the applicable Preferred Brand Name Drug or Non‐Preferred Brand Name Drug Copayment if the prescription has no generic equivalent. If You receive a Brand Name Drug when a generic equivalent is available, the Copayment will be the total of the Generic Drug Copayment plus the difference between the cost of the Generic Drug equivalent and the cost of the Brand Name Drug. About Your Benefits
How Copayment Amounts Apply. If the Allowable Amount of the Drug is less than the Copayment, You pay the lower cost. You will pay no more than the applicable Preferred Brand Name Drug or Non- Preferred Brand Name Drug Copayment if the prescription has no generic equivalent. If You receive a Brand Name Drug when a generic equivalent is available, the Copayment will be the total of the Generic Drug Copayment plus the difference between the cost of the Generic Drug equivalent and the cost of the Brand Name Drug. Exceptions to this may be allowed for certain preventive medications (including prescription contraceptive medications) if Your Health Care Practitioner submits a request to HMO indicating that the Generic Drug would be medically inappropriate, along with supporting documentation. If HMO grants the exception request, any difference between the Allowable Amount for the Brand Name Drug and the Generic Drug equivalent will be waived. About Your Benefits