Limitations on Quantities Dispensed Clause Samples

Limitations on Quantities Dispensed. This Contract will pay for the dispensing of up to a 90-Day Supply of Covered Drugs on each occasion when You have a Prescription Order filled or refilled. The applicable Copayment Amount is shown on Your Schedule of Coverage. Payment for benefits covered under this Contract may be denied if drugs are dispensed or delivered in a manner intended to change, or having the effect of changing or circumventing, the quantity limitations described above. For instance, if You obtain multiple refills for the same Prescription Order before the original supply is consumed. Article V - Limitations and Exclusions 1. The benefits as described in Article IV, Section 1, of this Contract are not available for: a. Any services or supplies for Eligible Expenses incurred for a Preexisting Condition during a period of 12 months beginning with the Participant’s Effective Date under this Contract. This Preexisting Condition exclusion shall not apply to a Participant: (1) Who was continuously covered for an aggregate of 18 months under Creditable Coverage if the previous coverage was in effect up to a date not more than 63 days before the Effective Date of the Participant’s coverage under this Contract, excluding any waiting periods; and (2) Whose most recent Creditable Coverage was under a group health plan, a governmental plan, or a church plan. If a Participant’s most recent Creditable Coverage was under a group health plan, a governmental plan, or a church plan, but the Participant does not have aggregate Creditable Coverage totaling 18 months, We will credit the time the Participant was previously covered under Creditable Coverage if the previous coverage was in effect at any time during the 18 months preceding (1) the first day coverage is effective under this Contract if there is not a waiting period, or (2) the day the applicant files a substantially complete application for coverage if there is a waiting period. b. Any services and supplies provided to any Participant for Maternity Care. c. Any services or supplies which are not Medically Necessary and essential to the diagnosis or direct care and treatment of a sickness, injury, condition, disease, or bodily malfunction; or any Experimental/Investigational services and supplies.