Common use of How Copayment Amounts Apply Clause in Contracts

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. 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. 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 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. 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, 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 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 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 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. Drug Exceptions 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 may be allowed for certain preventive medications (including prescription contraceptive medications) if Your Health Care Practitioner submits a request to HMO indicating that Certificate. The total benefits payable will not exceed the Generic Drug would be medically inappropriate, along with supporting documentation. If HMO grants the exception request, any difference between 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 Preferred Drug List. A Preferred Brand Name Drug is subject to the Preferred Brand Name Drug Copayment plus any applicable pricing differences. These drugs are identified on the Preferred drug list. HMO will periodically review the preferred drug list and adjust it to modify the Generic preferred/non- preferred Brand Name Drug equivalent status of new and existing drugs. Changes to the preferred drug list will be waivedimplemented on the next renewal date of the Group Agreement. How Member Payment The applicable preferred drug list is Determinedindicated in the SCHEDULE OF COPAYMENTS AND BENEFITS LIMITS. Prescription The preferred drug products are separated into tierslist and any modifications thereto will be made available to Members. Generally, each Preferred drug list is placed into one of six drug tiers: About available by accessing the website at ▇▇▇.▇▇▇▇▇▇.▇▇▇\pharmacy or by contacting customer service at the toll- free number on Your Benefits Covered Drug Listidentification card. Drugs listed that do not appear on Preferred drug list may be subject to the Non- Preferred Drug List are selected by HMO based upon the recommendations of a committee, which is made up of current Copayment 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 Listany applicable pricing differences.