Mail Order. Up to a 90-consecutive-calendar-day supply of covered Maintenance Drugs will be dispensed at the applicable mail order Copayment or Coinsurance. However, when the retail Copayment is a percentage, the mail order Copayment is the same percentage of the cost to Health Net as the retail Copayment. Platinum 90 Ambetter PPO AI-AN Diabetic supplies (blood glucose testing strips, lancets, disposable needles and syringes) are packaged in 50, 100, or 200 unit packages. Packages cannot be "broken" (i.e., opened in order to dispense the product in quantities other than those packaged). When a prescription is dispensed, you will receive the size of package and/or number of packages required for you to test the number of times your Physician has prescribed for up to a 30-day period. Tier 4 Drugs (Specialty Drugs) are specific Prescription Drugs that may have limited pharmacy availability or distribution, may be self-administered orally, topically, by inhalation, or by injection (either subcutaneously, intramuscularly or intravenously) requiring the Member to have special training or clinical monitoring for self-administration, includes drugs that the FDA or drug manufacturer requires to be distributed through a specialty pharmacy, or have high cost as established by Covered California. Tier 4 Drugs (Specialty Drugs) are identified in the Essential Drug List with “SP,” require Prior Authorization from Health Net and may be required to be dispensed through the specialty pharmacy vendor to be covered. Tier 4 Drugs (Specialty Drugs) are not available through mail order. Platinum 90 Ambetter PPO AI-AN Refer to the "Pediatric Dental Services" portion of the "Covered Services and Supplies" section of this All of the following services must be provided by a Health Net participating dental provider in order to be covered. Refer to the "Pediatric Dental Services" portion of the "Exclusions and Limitations" section for additional limitations on covered dental services. Pediatric dental services are covered until the last day of the month in which the individual turns nineteen years of age. If you have purchased a supplemental pediatric dental benefit plan, pediatric dental benefits covered under this Plan will be paid first, with the supplemental pediatric dental benefit plan covering noncovered services and or cost-sharing as described in your supplemental pediatric dental benefit plan coverage document. IMPORTANT: If you opt to receive dental services that are not covered services under this Plan Contract, a participating dental provider may charge you their usual and customary rate for those services. Prior to providing a patient with dental services that are not covered benefits, the dentist should provide to the patient a treatment plan that includes each anticipated service to be provided and the estimated cost of each service. If you would like more information about dental coverage options, you may call member services at (▇▇▇) ▇▇▇-▇▇▇▇ or your insurance broker. To fully understand your coverage, you may wish to carefully review this Plan Contract. Administration of these pediatric dental plan designs comply with requirements of the pediatric dental EHB benchmark plan, including coverage of services in circumstances of Medical Necessity as defined in the Early Periodic Screening, Diagnosis and Treatment (EPSDT) benefit for pediatric dental services. Benefit limits are calculated on a Calendar Year basis unless otherwise specifically stated.
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Mail Order. Up to a 90-consecutive-calendar-day supply of covered Maintenance Drugs will be dispensed at the applicable mail order Copayment or Coinsurance. However, when the retail Copayment is a percentage, the mail order Copayment is the same percentage of the cost to Health Net as the retail Copayment. Platinum 90 Ambetter PPO AI-AN Diabetic supplies (blood glucose testing strips, lancets, disposable needles and syringes) are packaged in 50, 100, or 200 unit packages. Packages cannot be "broken" (i.e., opened in order to dispense the product in quantities other than those packaged). When a prescription is dispensed, you will receive the size of package and/or number of packages required for you to test the number of times your Physician has prescribed for up to a 30-day period. Tier 4 Drugs (Specialty Drugs) are specific Prescription Drugs that may have limited pharmacy availability or distribution, may be self-administered orally, topically, by inhalation, or by injection (either subcutaneously, intramuscularly or intravenously) requiring the Member to have special training or clinical monitoring for self-administration, includes drugs that the FDA or drug manufacturer requires to be distributed through a specialty pharmacy, or have high cost as established by Covered California. Tier 4 Drugs (Specialty Drugs) are identified in the Essential Drug List with “SP,” require Prior Authorization from Health Net and may be required to be dispensed through the specialty pharmacy vendor to be covered. Tier 4 Drugs (Specialty Drugs) are not available through mail order. Platinum 90 Ambetter PPO AI-AN Refer to the "Pediatric Dental Services" portion of the "Covered Services and Supplies" section of this All of the following services must be provided by a Health Net participating dental provider in order to be covered. Refer to the "Pediatric Dental Services" portion of the "Exclusions and Limitations" section for additional limitations on covered dental services. Pediatric dental services are covered until the last day of the month in which the individual turns nineteen years of age. If you have purchased a supplemental pediatric dental benefit plan, pediatric dental benefits covered under this Plan will be paid first, with the supplemental pediatric dental benefit plan covering noncovered services and or cost-sharing as described in your supplemental pediatric dental benefit plan coverage document. IMPORTANT: If you opt to receive dental services that are not covered services under this Plan Contract, a participating dental provider may charge you their usual and customary rate for those services. Prior to providing a patient with dental services that are not covered benefits, the dentist should provide to the patient a treatment plan that includes each anticipated service to be provided and the estimated cost of each service. If you would like more information about dental coverage options, you may call member services at (▇▇▇) ▇▇▇-▇▇▇▇ or your insurance broker. To fully understand your coverage, you may wish to carefully review this Plan Contract. Administration of these pediatric dental plan designs comply with requirements of the pediatric dental EHB benchmark plan, including coverage of services in circumstances of Medical Necessity as defined in the Early Periodic Screening, Diagnosis and Treatment (EPSDT) benefit for pediatric dental services. Benefit limits are calculated on a Calendar Year basis unless otherwise specifically stated.
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