Outpatient Services. After Deductible, Member pays 20% Plan Coinsurance Injections administered by a Network Provider in a clinical setting during dialysis. Outpatient Services: After Deductible, Member pays 20% Plan Coinsurance Self-administered injectables. See Drugs – Outpatient Prescription for additional pharmacy information. Preferred generic drugs (Tier 1): After Deductible, Member pays $15 Copayment per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): After Deductible, Member pays $30 Copayment per 30- days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): Not covered; Member pays 100% of all charges Drugs - Outpatient Prescription Prescription drugs, supplies and devices for a supply of 30 days or less including diabetic pharmacy supplies (insulin, lancets, lancet devices, needles, insulin syringes, insulin pens, pen needles and blood glucose test strips), mental health and wellness drugs, self-administered injectables, medications for the treatment arising from sexual assault, and routine costs for prescription medications provided in a clinical trial. “Routine costs” means items and services delivered to the Member that are consistent with and typically covered by the plan or coverage for a Member who is not enrolled in a clinical trial. All drugs, supplies and devices must be for Covered Services. All drugs, supplies and devices must be obtained at a KFHPWA-designated pharmacy except for drugs dispensed for Emergency services or for Emergency services obtained outside of the KFHPWA Service Area including out of the country. Information regarding KFHPWA-designated pharmacies is reflected in the KFHPWA Provider Directory or can be obtained by contacting Xxxxxx Permanente Member Services. Prescription drug Cost Shares are payable at the time of delivery. Certain brand name insulin drugs are covered at the generic drug Cost Share. Preferred generic drugs (Tier 1): After Deductible, Member pays $15 Copayment per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): After Deductible, Member pays $30 Copayment per 30- days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): Not covered; Member pays 100% of all charges Annual Deductible does not apply to glucose monitors, test strips, lancets or control solutions. Note: A Member will not pay more than $100, not subject to the Deductible, for a 30-day supply of insulin to comply with state law requirements. Any cost sharing paid will apply toward the annual Deductible. Members may be eligible to receive an emergency fill for certain prescription drugs filled outside of KFHPWA’s business hours or when KFHPWA cannot reach the prescriber for consultation. For emergency fills, Members pay the prescription drug Cost Share for each 7-day supply or less, or the minimum packaging size available at the time the emergency fill is dispensed. A list of prescription drugs eligible for emergency fills is available on the pharmacy website at xxx.xx.xxx/xx/xxxxxxxxx. Members can request an emergency fill by calling 0-000-000-0000. Certain drugs are subject to Preauthorization as shown in the Preferred drug list (formulary) available at xxx.xx.xxx/xx/xxxxxxxxx. Injections administered by a Network Provider in a clinical setting. After Deductible, Member pays 20% Plan Coinsurance Over-the-counter drugs not included under Preventive Care or Reproductive Health. Not covered; Member pays 100% of all charges Mail order drugs dispensed through the KFHPWA-designated mail order service. Member pays the prescription drug Cost Share for each 30 day supply or less Annual Deductible does not apply to glucose monitors, test strips, lancets or control solutions. Note: A Member will not pay more than $100, not subject to the Deductible, for a 30-day supply of insulin to comply with state law requirements. Any cost sharing paid will apply toward the annual Deductible. The KFHPWA Preferred drug list is a list of prescription drugs, supplies, and devices considered to have acceptable efficacy, safety and cost-effectiveness. The Preferred drug list is maintained by a committee consisting of a group of physicians, pharmacists and a consumer representative who review the scientific evidence of these products and determine the Preferred and Non-Preferred status as well as utilization management requirements. Preferred drugs generally have better scientific evidence for safety and effectiveness and are more affordable than Non-Preferred drugs. The preferred drug list is available at xxx.xx.xxx/xx/xxxxxxxxx, or upon request from Member Services. Members may request a coverage determination by contacting Member Services. Coverage determination reviews may include requests to cover non-preferred drugs, obtain Preauthorization for a specific drug, or exceptions to other utilization management requirements, such as quantity limits. If coverage of a non-Preferred drug is approved, the drug will be covered at the Preferred drug level. Prescription drugs are drugs which have been approved by the Food and Drug Administration (FDA) and which can, under federal or state law, be dispensed only pursuant to a prescription order. These drugs, including off-label use of FDA-approved drugs (provided that such use is documented to be effective in one of the standard reference compendia; a majority of well-designed clinical trials published in peer-reviewed medical literature document improved efficacy or safety of the agent over standard therapies, or over placebo if no standard therapies exist; or by the federal secretary of Health and Human Services) are covered. “Standard reference compendia” means the American Hospital Formulary Service – Drug Information; the American Medical Association Drug Evaluation; the United States Pharmacopoeia – Drug Information, or other authoritative compendia as identified from time to time by the federal secretary of Health and Human Services. “Peer-reviewed medical literature” means scientific studies printed in health care journals or other publications in which original manuscripts are published only after having been critically reviewed for scientific accuracy, validity and reliability by unbiased independent experts. Peer-reviewed medical literature does not include in-house publications of pharmaceutical manufacturing companies. Generic drugs are dispensed whenever available. A generic drug is a drug that is the pharmaceutical equivalent to one or more brand name drugs. Such generic drugs have been approved by the Food and Drug Administration as meeting the same standards of safety, purity, strength and effectiveness as the brand name drug. Brand name drugs are dispensed if there is not a generic equivalent. In the event the Member elects to purchase a brand-name drug instead of the generic equivalent (if available), the Member is responsible for paying the difference in cost in addition to the prescription drug Cost Share which does not apply to the Out-of-pocket Limit. Drug coverage is subject to utilization management that includes Preauthorization, step therapy (when a Member tries a certain medication before receiving coverage for a similar, but non-Preferred medication), limits on drug quantity or days supply and prevention of overutilization, underutilization, therapeutic duplication, drug-drug interactions, incorrect drug dosage, drug-allergy contraindications and clinical abuse/misuse of drugs. If a Member has a new prescription for a chronic condition, the Member may request a coordination of medications so that medications for chronic conditions are refilled on the same schedule (synchronized). Cost-shares for the initial fill of the medication will be adjusted if the fill is less than the standard quantity. Please contact Member Services for more information. Specialty drugs are high-cost drugs prescribed by a physician that requires close supervision and monitoring for serious and/or complex conditions, such as rheumatoid arthritis, hepatitis or multiple sclerosis. Specialty drugs must be obtained through KFHPWA’s preferred specialty pharmacy vendor and/or network of specialty pharmacies and are covered at the appropriate cost share above. For a list of specialty drugs or more information about KFHPWA’s specialty pharmacy network, please go to the KFHPWA website at xxx.xx.xxx/xx/xxxxxxxxx or contact Member Services at 206-630-4636 or toll-free at 1-888-901-4636. The Member’s Right to Safe and Effective Pharmacy Services: State and federal laws establish standards to assure safe and effective pharmacy services, and to guarantee Members’ right to know what drugs are covered and the coverage limitations. Members who would like more information about the drug coverage policies, or have a question or concern about their pharmacy benefit, may contact KFHPWA at 000-000-0000 or toll-free 1-888-901-4636 or by accessing the KFHPWA website at xxx.xx.xxx/xx. Members who would like to know more about their rights under the law, or think any services received while enrolled may not conform to the terms of the EOC, may contact the Washington State Office of Insurance Commissioner at toll-free 1-800-562-6900. Members who have a concern about the pharmacists or pharmacies serving them may call the Washington State Department of Health at toll-free 0-000-000-0000. Prescription Drug Coverage and Medicare: This benefit, for purposes of Creditable Coverage, is actuarially equal to or greater than the Medicare Part D prescription drug benefit. Members who are also eligible for Medicare Part D can remain covered and will not be subject to Medicare-imposed late enrollment penalties should they decide to enroll in a Medicare Part D plan at a later date; however, the Member could be subject to payment of higher Part D premiums if the Member subsequently has a break in creditable coverage of 63 continuous days or longer before enrolling in a Part D plan. A Member who discontinues coverage must meet eligibility requirements in order to re- enroll. Exclusions: Over-the-counter drugs, supplies and devices not requiring a prescription under state law or regulations, including most prescription vitamins, except as recommended by the U.S. Preventive Services Task Force (USPSTF); drugs and injections for anticipated illness while traveling; drugs and injections for cosmetic purposes; replacement of lost, stolen, or damaged drugs or devices; administration of excluded drugs and injectables; drugs used in the treatment of sexual dysfunction disorders; compounds which include a non-FDA approved drug; growth hormones for idiopathic short stature without growth hormone deficiency; prescription drugs/products available over-the-counter or have an over-the-counter alternative that is determined to be therapeutically interchangeable Emergency Services Emergency services at a Network Facility or non-Network Facility. See Section XII. for a definition of Emergency. Emergency services include professional services, treatment and supplies, facility costs, outpatient charges for patient observation and medical screening exams required to stabilize a patient. Members must notify KFHPWA by way of the Hospital notification line within 24 hours of any admission, or as soon thereafter as medically possible. If a Member is admitted as an inpatient directly from an emergency department, any Emergency services Copayment is waived. Coverage is subject to the hospital services Cost Share. If a Member is hospitalized in a non-Network Facility, KFHPWA reserves the right to require transfer of the Member to a Network Facility upon consultation between a Network Provider and the attending physician. If the Member refuses to transfer to a Network Facility or does not notify KFHPWA within 24 hours following admission, all further costs incurred during the hospitalization are the responsibility of the Member. Follow-up care which is a direct result of the Emergency must be received from a Network Provider, unless Preauthorization is obtained for such follow-up care from a non-Network Provider. Network Facility: After Deductible, Member pays 20% Plan Coinsurance Non-Network Facility: After Deductible, Member pays 20% Plan Coinsurance Hearing Examinations and Hearing Aids Hearing exams for hearing loss and evaluation are covered only when provided at KFHPWA-approved facilities. Cochlear implants or Bone Anchored Hearing Aids (BAHA) when in accordance with KFHPWA clinical criteria. Covered services for cochlear implants and BAHA include diagnostic testing, pre-implant testing, implant surgery, post- implant follow-up, speech therapy, programming and associated supplies (such as transmitter cable, and batteries). Hospital - Inpatient: After Deductible, Member pays 20% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 20% Plan Coinsurance Outpatient Services: After Deductible, Member pays 20% Plan Coinsurance Hearing aids including hearing aid examinations. Not covered; Member pays 100% of all charges Exclusions: Programs or treatments for hearing loss or hearing care including, but not limited to, externally worn hearing or surgically implanted hearing aids and the surgery and services necessary to implant them except as described above; hearing screening tests required under Preventive Services Home Health Care

Appears in 6 contracts

Samples: Group Medical Coverage Agreement, Group Medical Coverage Agreement, Group Medical Coverage Agreement

Outpatient Services. After Deductible, Member pays 20% Plan Coinsurance Injections administered by a Network Provider in a clinical setting during dialysis. Outpatient Services: After Deductible, Member pays 20% Plan Coinsurance Self-administered injectables. See Drugs – Outpatient Prescription for additional pharmacy information. Preferred generic drugs (Tier 1): After Deductible, Member pays $15 Copayment per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): After Deductible, Member pays $30 Copayment per 30- days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): Not covered; Member pays 100% of all charges Drugs - Outpatient Prescription Prescription drugs, supplies and devices for a supply of 30 days or less including diabetic pharmacy supplies (insulin, lancets, lancet devices, needles, insulin syringes, disposable insulin pens, pen needles and blood glucose test strips), mental health and wellness drugs, self-administered injectables, medications for the treatment arising from sexual assault, and routine costs for prescription medications provided in a clinical trial. “Routine costs” means items and services delivered to the Member that are consistent with and typically covered by the plan or coverage for a Member who is not enrolled in a clinical trial. All drugs, supplies and devices must be for Covered Services. All drugs, supplies and devices must be obtained at a KFHPWA-designated pharmacy except for drugs dispensed for Emergency services or for Emergency services obtained outside of the KFHPWA Service Area including out of the country. Information regarding KFHPWA-designated pharmacies is reflected in the KFHPWA Provider Directory or can be obtained by contacting Xxxxxx Permanente Member Services. Prescription drug Cost Shares are payable at the time of delivery. Certain brand name insulin drugs are covered at the generic drug Cost Share. Preferred generic drugs (Tier 1): After Deductible, Member pays $15 Copayment per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): After Deductible, Member pays $30 Copayment per 30- days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): Not covered; Member pays 100% of all charges ~~Annual Deductible does not apply to glucose monitors~~All drugs, ~~test strips~~supplies and devices must be obtained at a KFHPWA-designated pharmacy except for drugs dispensed for Emergency services or for Emergency services obtained outside of the KFHPWA Service Area, ~~lancets~~ including out of the country. Information regarding KFHPWA-designated pharmacies is reflected in the KFHPWA Provider Directory or ~~control solutions~~can be obtained by contacting Xxxxxx Permanente Member Services. ~~Note: A Member will not pay more than $100, not subject to~~ Prescription drug Cost Shares are payable at the ~~Deductible, for a 30-day supply~~ time of delivery. Certain brand name insulin ~~to comply with state law requirements. Any cost sharing paid will apply toward~~ drugs are covered at the ~~annual Deductible~~generic drug Cost Share. Members may be eligible to receive an emergency fill for certain prescription drugs filled outside of KFHPWA’s business hours or when KFHPWA cannot reach the prescriber for consultation. For emergency fills, Members pay the prescription drug Cost Share for each 7-day supply or less, or the minimum packaging size available at the time the emergency fill is dispensed. A list of prescription drugs eligible for emergency fills is available on the pharmacy website at xxx.xx.xxx/xx/xxxxxxxxx. Members can request an emergency fill by calling 0-000-000-0000. Certain drugs are subject to Preauthorization as shown in the Preferred drug list (formulary) available at xxx.xx.xxx/xx/xxxxxxxxx. Certain drugs are subject to Preauthorization as shown in the Preferred drug list (formulary) available at xxx.xx.xxx/xx/xxxxxxxxx. Annual Deductible does not apply to strip-based blood glucose monitors, test strips, lancets or control solutions. Note: A Member will not pay more than $100, not subject to the Deductible, for a 30-day supply of insulin to comply with state law requirements. Any cost sharing paid will apply toward the annual Deductible. Injections administered by a Network Provider in a clinical setting. After Deductible, Member pays 20% Plan Coinsurance Over-the-counter drugs not included under Preventive Care or Reproductive Health. Not covered; Member pays 100% of all charges Mail order drugs dispensed through the KFHPWA-designated mail order service. Member pays the prescription drug Cost Share for each 30 day supply or less Annual Deductible does not apply to strip-based blood glucose monitors, test strips, lancets or control solutions. Note: A Member will not pay more than $100, not subject to the Deductible, for a 30-day supply of insulin to comply with state law requirements. Any cost sharing paid will apply toward the annual Deductible. The KFHPWA Preferred drug list is a list of prescription drugs, supplies, and devices considered to have acceptable efficacy, safety and cost-effectiveness. The Preferred drug list is maintained by a committee consisting of a group of physicians, pharmacists and a consumer representative who review the scientific evidence of these products and determine the Preferred and Non-Preferred status as well as utilization management requirements. Preferred drugs generally have better scientific evidence for safety and effectiveness and are more affordable than Non-Preferred drugs. The preferred drug list is available at xxx.xx.xxx/xx/xxxxxxxxx, or upon request from Member Services. Members may request a coverage determination by contacting Member Services. Coverage determination reviews may include requests to cover non-preferred drugs, obtain Preauthorization for a specific drug, or exceptions to other utilization management requirements, such as quantity limits. If coverage of a non-Preferred drug is approved, the drug will be covered at the Preferred drug level. Prescription drugs are drugs which have been approved by the Food and Drug Administration (FDA) and which can, under federal or state law, be dispensed only pursuant to a prescription order. These drugs, including off-label use of FDA-approved drugs (provided that such use is documented to be effective in one of the standard reference compendia; a majority of well-designed clinical trials published in peer-reviewed medical literature document improved efficacy or safety of the agent over standard therapies, or over placebo if no standard therapies exist; or by the federal secretary of Health and Human Services) are covered. “Standard reference compendia” means the American Hospital Formulary Service – Drug Information; the American Medical Association Drug Evaluation; the United States Pharmacopoeia – Drug Information, or other authoritative compendia as identified from time to time by the federal secretary of Health and Human Services. “Peer-reviewed medical literature” means scientific studies printed in health care journals or other publications in which original manuscripts are published only after having been critically reviewed for scientific accuracy, validity and reliability by unbiased independent experts. Peer-reviewed medical literature does not include in-house publications of pharmaceutical manufacturing companies. Generic drugs are dispensed whenever available. A generic drug is a drug that is the pharmaceutical equivalent to one or more brand name drugs. Such generic drugs have been approved by the Food and Drug Administration as meeting the same standards of safety, purity, strength and effectiveness as the brand name drug. Brand name drugs are dispensed if there is not a generic equivalent. In the event the Member elects to purchase a brand-name drug instead of the generic equivalent (if available), the Member is responsible for paying the difference in cost in addition to the prescription drug Cost Share which does not apply to the Out-of-pocket Limit. Drug coverage is subject to utilization management that includes Preauthorization, step therapy (when a Member tries a certain medication before receiving coverage for a similar, but non-Preferred medication), limits on drug quantity or days supply and prevention of overutilization, underutilization, therapeutic duplication, drug-drug interactions, incorrect drug dosage, drug-allergy contraindications and clinical abuse/misuse of drugs. If a Member has a new prescription for a chronic condition, the Member may request a coordination of medications so that medications for chronic conditions are refilled on the same schedule (synchronized). Cost-shares for the initial fill of the medication will be adjusted if the fill is less than the standard quantity. Please contact Member Services for more information. Specialty drugs are high-cost drugs prescribed by a physician that requires close supervision and monitoring for serious and/or complex conditions, such as rheumatoid arthritis, hepatitis or multiple sclerosis. Specialty drugs must be obtained through KFHPWA’s preferred specialty pharmacy vendor and/or network of specialty pharmacies and are covered at the appropriate cost share above. For a list of specialty drugs or more information about KFHPWA’s specialty pharmacy network, please go to the KFHPWA website at xxx.xx.xxx/xx/xxxxxxxxx or contact Member Services at 206-630-4636 or toll-free at 1-888-901-4636. The Member’s Right to Safe and Effective Pharmacy Services: State and federal laws establish standards to assure safe and effective pharmacy services, and to guarantee Members’ right to know what drugs are covered and the coverage limitations. Members who would like more information about the drug coverage policies, or have a question or concern about their pharmacy benefit, may contact KFHPWA at 000-000-0000 or toll-free 1-888-901-4636 or by accessing the KFHPWA website at xxx.xx.xxx/xx. Members who would like to know more about their rights under the law, or think any services received while enrolled may not conform to the terms of the EOC, may contact the Washington State Office of Insurance Commissioner at toll-free 1-800-562-6900. Members who have a concern about the pharmacists or pharmacies serving them may call the Washington State Department of Health at toll-free 0-000-000-0000. Prescription Drug Coverage and Medicare: This benefit, for purposes of Creditable Coverage, is actuarially equal to or greater than the Medicare Part D prescription drug benefit. Members who are also eligible for Medicare Part D can remain covered and will not be subject to Medicare-imposed late enrollment penalties should they decide to enroll in a Medicare Part D plan at a later date; however, the Member could be subject to payment of higher Part D premiums if the Member subsequently has a break in creditable coverage of 63 continuous days or longer before enrolling in a Part D plan. A Member who discontinues coverage must meet eligibility requirements in order to re- enroll. Exclusions: Over-the-counter drugs, supplies and devices not requiring a prescription under state law or regulations, including most prescription vitamins, except as recommended by the U.S. Preventive Services Task Force (USPSTF); drugs and injections for anticipated illness while traveling; drugs and injections for cosmetic purposes; replacement of lost, stolen, or damaged drugs or devices; administration of excluded drugs and injectables; drugs used in the treatment of sexual dysfunction disorders; compounds which include a non-FDA approved drug; growth hormones for idiopathic short stature without growth hormone deficiency; prescription drugs/products available over-the-counter or have an over-the-counter alternative that is determined to be therapeutically interchangeable Emergency Services Emergency services at a Network Facility or non-Network Facility. See Section XII. for a definition of Emergency. Emergency services include professional services, treatment and supplies, facility costs, outpatient charges for patient observation and medical screening exams required to stabilize a patient. Members must notify KFHPWA by way of the Hospital notification line within 24 hours of any admission, or as soon thereafter as medically possible. If a Member is admitted as an inpatient directly from an emergency department, any Emergency services Copayment is waived. Coverage is subject to the hospital services Cost Share. If a Member is hospitalized in a non-Network Facility, KFHPWA reserves the right to require transfer of the Member to a Network Facility upon consultation between a Network Provider and the attending physician. If the Member refuses to transfer to a Network Facility or does not notify KFHPWA within 24 hours following admission, all further costs incurred during the hospitalization are the responsibility of the Member. Follow-up care which is a direct result of the Emergency must be received from a Network Provider, unless Preauthorization is obtained for such follow-up care from a non-Network Provider. Network Facility: After Deductible, Member pays 20% Plan Coinsurance Non-Network Facility: After Deductible, Member pays 20% Plan Coinsurance Hearing Examinations and Hearing Aids Hearing exams for hearing loss and evaluation are covered only when provided at KFHPWA-approved facilities. Cochlear implants or Bone Anchored Hearing Aids (BAHA) when in accordance with KFHPWA clinical criteria. Covered services for cochlear implants and BAHA include diagnostic testing, pre-implant testing, implant surgery, post- implant follow-up, speech therapy, programming and associated supplies (such as transmitter cable, and batteries). Hospital - Inpatient: After Deductible, Member pays 20% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 20% Plan Coinsurance Outpatient Services: After Deductible, Member pays 20% Plan Coinsurance Hearing aids including hearing aid examinations. Not covered; Member pays 100% of all charges Exclusions: Programs or treatments for hearing loss or hearing care including, but not limited to, externally worn hearing or surgically implanted hearing aids and the surgery and services necessary to implant them except as described above; hearing screening tests required under Preventive Services Home Health Care.

Appears in 3 contracts

Samples: Group Medical Coverage Agreement, Group Medical Coverage Agreement, Group Medical Coverage Agreement

Outpatient Services. After Deductible, Member pays 2010% Plan Coinsurance Enhanced Benefit: After Deductible, Member pays 5% Plan Coinsurance Outpatient Services: After Deductible, Member pays 30% Plan Coinsurance Injections administered by a ~~Network~~ Provider in a clinical setting during dialysis. Outpatient Services: After Deductible, Member pays 2010% Plan Coinsurance Enhanced Benefit: After Deductible, Member pays 5% Plan Coinsurance Outpatient Services: After Deductible, Member pays 30% Plan Coinsurance Self-administered injectables. See Drugs – Outpatient Prescription for additional pharmacy information. Preferred generic drugs (Tier 1): ~~After Deductible,~~ Member pays $15 Copayment per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): ~~After Deductible,~~ Member pays $30 25 Copayment per ~~30-~~ 30-days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): Member pays $45 Copayment per 30- days up to a 90-day supply Enhanced Benefit: Preferred generic drugs (Tier 1): Member pays $10 Copayment per 30-days up to a 90-day supply Preferred brand name Not covered; Member pays 100% of all charges drugs (Tier 2): Member pays $20 Copayment per 30-days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): Member pays $40 Copayment per 30- days up to a 90-day supply Drugs - Outpatient Prescription Preferred Provider Network Out-of-Network Prescription drugs, supplies and devices for a supply of 30 days or less including diabetic pharmacy supplies (insulin, lancets, lancet devices, needles, insulin syringes, insulin pens, pen needles and blood glucose test strips), mental health and wellness drugs, self-administered injectables, medications for the treatment arising from sexual assault, and routine costs for prescription medications provided in a clinical trial. “Routine costs” means items and services delivered to the Member that are consistent with and typically covered by the plan or coverage for a Member who is not enrolled in a clinical trial. All drugs, supplies and devices must be for Covered Services. All drugs, supplies and devices must be obtained at a ~~KFHPWA~~KFHPWAO-designated pharmacy except for drugs dispensed for Emergency services or for Emergency services obtained outside of the ~~KFHPWA~~ KFHPWAO Service ~~Area~~ Area, including out of the country. Information regarding ~~KFHPWA~~KFHPWAO-designated pharmacies is reflected in the ~~KFHPWA~~ KFHPWAO Provider Directory or can be obtained by contacting Xxxxxx Permanente Member Services. Prescription drug Cost Shares are payable at the time of delivery. Certain brand name insulin drugs are covered at the generic drug Cost Share. ~~Preferred generic~~ Certain drugs (Tier 1): After Deductible, Member pays $15 Copayment per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): After Deductible, Member pays $30 Copayment per 30- days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): Not covered; Member pays 100% of all charges Annual Deductible does not apply to glucose monitors, test strips, lancets or control solutions. Note: A Member will not pay more than $100, not are subject to Preauthorization as shown in the ~~Deductible, for a 30-day supply of insulin to comply with state law requirements. Any cost sharing paid will apply toward the annual Deductible~~Preferred drug list (formulary) available at xxx.xx.xxx/xx/xxxxxxxxx. Members may be eligible to receive an emergency fill for certain prescription drugs filled outside of ~~KFHPWA~~KFHPWAO’s business hours or when ~~KFHPWA~~ KFHPWAO cannot reach the prescriber for consultation. For emergency fills, Members pay the prescription drug Cost Share for each 7-day supply or less, or the minimum packaging size available at the time the emergency fill is dispensed. A list of prescription drugs eligible for emergency fills is available on the pharmacy Preferred generic drugs (Tier 1): Member pays $15 Copayment per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): Member pays $25 Copayment per 30-days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): Member pays $45 Copayment per 30- days up to a 90-day supply Enhanced Benefit: Preferred generic drugs (Tier 1): Member pays $10 Copayment per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): Member pays $20 Copayment per 30-days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): Member pays $40 Copayment per 30- Not covered; Member pays 100% of all charges website at xxx.xx.xxx/xx/xxxxxxxxx. Members can request an emergency fill by calling 0-000-000-0000. ~~Certain drugs~~ days up to a 90-day supply In order to obtain the enhanced benefits, Members must utilize designated pharmacies, which are ~~subject to Preauthorization as shown~~ reflected in the ~~Preferred drug list (formulary) available at xxx.xx.xxx/xx/xxxxxxxxx~~KFHPWAO Provider Directory, or can be obtained by contacting Xxxxxx Permanente Member Services. Annual Deductible does not apply to the glucose monitors, test strips, lancets or control solutions Note: A Member will not pay more than $100 for a 30-day supply of insulin to comply with state law requirements. Injections administered by a ~~Network~~ Provider in a clinical setting. After Deductible, Member pays 2010% Plan Coinsurance After Deductible, Member pays 30% Plan Coinsurance Enhanced Benefit: After Deductible, Member pays 5% Plan Coinsurance Over-the-counter drugs not included under Preventive Care or Reproductive Health. Not covered; Member pays 100% of all charges Not covered; Member pays 100% of all charges Mail order drugs dispensed through the ~~KFHPWA-~~KFHPWAO- designated mail order service. Member pays two times the Enhanced Benefit prescription drug Cost Share for each 30 90-day supply or less Not covered; Member pays 100% of all charges Annual Deductible does not apply to the glucose monitors, test strips, lancets or control ~~solutions.~~ solutions Note: A Member will not pay more than $~~100, not subject to the Deductible,~~ 100 for a 30-day supply of insulin to comply with state law requirements. ~~Any cost sharing paid will apply toward the annual Deductible.~~ The ~~KFHPWA~~ KFHPWAO Preferred drug list is a list of prescription drugs, supplies, and devices considered to have acceptable efficacy, safety and cost-effectiveness. The Preferred drug list is maintained by a committee consisting of a group of physicians, pharmacists and a consumer representative who review the scientific evidence of these products and determine the Preferred and Non-Preferred status as well as utilization management requirements. Preferred ~~drugs generally have better scientific evidence for safety and effectiveness and are more affordable than Non-Preferred~~ drugs. The preferred drug list is available at xxx.xx.xxx/xx/xxxxxxxxx, or upon request from Member Services. Members may request a coverage determination by contacting Member Services. Coverage determination reviews may include requests to cover non-preferred drugs, obtain Preauthorization for a specific drug, or exceptions to other utilization management requirements, such as quantity limits. If coverage of a non-Preferred drug is approved, the drug will be covered at the Preferred drug level. Prescription drugs are drugs which have been approved by the Food and Drug Administration (FDA) and which can, under federal or state law, be dispensed only pursuant to a prescription order. These drugs, including off-label use of FDA-approved drugs (provided that such use is documented to be effective in one of the standard reference compendia; a majority of well-designed clinical trials published in peer-reviewed medical literature document improved efficacy or safety of the agent over standard therapies, or over placebo if no standard therapies exist; or by the federal secretary of Health and Human Services) are covered. “Standard reference compendia” means the American Hospital Formulary Service – Drug Information; the American Medical Association Drug Evaluation; the United States Pharmacopoeia – Drug Information, or other authoritative compendia as identified from time to time by the federal secretary of Health and Human Services. “Peer-reviewed medical literature” means scientific studies printed in health care journals or other publications in which original manuscripts are published only after having been critically reviewed for scientific accuracy, validity and reliability by unbiased independent experts. Peer-reviewed medical literature does not include in-house publications of pharmaceutical manufacturing companies. Generic drugs are dispensed whenever available. A generic drug is a drug that is the pharmaceutical equivalent to one or more brand name drugs. Such generic drugs have been approved by the Food and Drug Administration as meeting the same standards of safety, purity, strength and effectiveness as the brand name drug. Brand name drugs are dispensed if there is not a generic equivalent. In the event the Member elects to purchase a brand-name drug instead of the generic equivalent (if available), the Member is responsible for paying the difference in cost in addition to the prescription drug Cost Share which does not apply to the Out-of-pocket Limit. Drug coverage is subject to utilization management that includes Preauthorization, step therapy (when a Member tries a certain medication before receiving coverage for a similar, but non-Preferred medication), limits on drug quantity or days supply and prevention of overutilization, underutilization, therapeutic duplication, drug-drug interactions, incorrect drug dosage, drug-allergy contraindications and clinical abuse/misuse of drugs. If a Member has a new prescription for a chronic condition, the Member may request a coordination of medications so that medications for chronic conditions are refilled on the same schedule (synchronized). Cost-shares for the initial fill of the medication will be adjusted if the fill is less than the standard quantity. Please contact Member Services for more information. Specialty drugs are high-cost drugs prescribed by a physician that requires close supervision and monitoring for serious and/or complex conditions, such as rheumatoid arthritis, hepatitis or multiple sclerosis. Specialty drugs must be obtained through KFHPWA’s preferred specialty pharmacy vendor and/or network of specialty pharmacies and are covered at the appropriate cost share above. For a list of specialty drugs or more information about KFHPWA’s specialty pharmacy network, please go to the KFHPWA website at xxx.xx.xxx/xx/xxxxxxxxx or contact Member Services at 206-630-4636 or toll-free at 1-888-901-4636. The Member’s Right to Safe and Effective Pharmacy Services: State and federal laws establish standards to assure safe and effective pharmacy services, and to guarantee Members’ right to know what drugs are covered and the coverage limitations. Members who would like more information about the drug coverage policies, or have a question or concern about their pharmacy benefit, may contact KFHPWA at 000-000-0000 or toll-free 1-888-901-4636 or by accessing the KFHPWA website at xxx.xx.xxx/xx. Members who would like to know more about their rights under the law, or think any services received while enrolled may not conform to the terms of the EOC, may contact the Washington State Office of Insurance Commissioner at toll-free 1-800-562-6900. Members who have a concern about the pharmacists or pharmacies serving them may call the Washington State Department of Health at toll-free 0-000-000-0000. Prescription Drug Coverage and Medicare: This benefit, for purposes of Creditable Coverage, is actuarially equal to or greater than the Medicare Part D prescription drug benefit. Members who are also eligible for Medicare Part D can remain covered and will not be subject to Medicare-imposed late enrollment penalties should they decide to enroll in a Medicare Part D plan at a later date; however, the Member could be subject to payment of higher Part D premiums if the Member subsequently has a break in creditable coverage of 63 continuous days or longer before enrolling in a Part D plan. A Member who discontinues coverage must meet eligibility requirements in order to re- enroll. Exclusions: Over-the-counter drugs, supplies and devices not requiring a prescription under state law or regulations, including most prescription vitamins, except as recommended by the U.S. Preventive Services Task Force (USPSTF); drugs and injections for anticipated illness while traveling; drugs and injections for cosmetic purposes; replacement of lost, stolen, or damaged drugs or devices; administration of excluded drugs and injectables; drugs used in the treatment of sexual dysfunction disorders; compounds which include a non-FDA approved drug; growth hormones for idiopathic short stature without growth hormone deficiency; prescription drugs/products available over-the-counter or have an over-the-counter alternative that is determined to be therapeutically interchangeable Emergency Services Emergency services at a Network Facility or non-Network Facility. See Section XII. for a definition of Emergency. Emergency services include professional services, treatment and supplies, facility costs, outpatient charges for patient observation and medical screening exams required to stabilize a patient. Members must notify KFHPWA by way of the Hospital notification line within 24 hours of any admission, or as soon thereafter as medically possible. If a Member is admitted as an inpatient directly from an emergency department, any Emergency services Copayment is waived. Coverage is subject to the hospital services Cost Share. If a Member is hospitalized in a non-Network Facility, KFHPWA reserves the right to require transfer of the Member to a Network Facility upon consultation between a Network Provider and the attending physician. If the Member refuses to transfer to a Network Facility or does not notify KFHPWA within 24 hours following admission, all further costs incurred during the hospitalization are the responsibility of the Member. Follow-up care which is a direct result of the Emergency must be received from a Network Provider, unless Preauthorization is obtained for such follow-up care from a non-Network Provider. Network Facility: After Deductible, Member pays 20% Plan Coinsurance Non-Network Facility: After Deductible, Member pays 20% Plan Coinsurance Hearing Examinations and Hearing Aids Hearing exams for hearing loss and evaluation are covered only when provided at KFHPWA-approved facilities. Cochlear implants or Bone Anchored Hearing Aids (BAHA) when in accordance with KFHPWA clinical criteria. Covered services for cochlear implants and BAHA include diagnostic testing, pre-implant testing, implant surgery, post- implant follow-up, speech therapy, programming and associated supplies (such as transmitter cable, and batteries). Hospital - Inpatient: After Deductible, Member pays 20% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 20% Plan Coinsurance Outpatient Services: After Deductible, Member pays 20% Plan Coinsurance Hearing aids including hearing aid examinations. Not covered; Member pays 100% of all charges Exclusions: Programs or treatments for hearing loss or hearing care including, but not limited to, externally worn hearing or surgically implanted hearing aids and the surgery and services necessary to implant them except as described above; hearing screening tests required under Preventive Services Home Health Care

Appears in 2 contracts

Samples: Medical Coverage Agreement, Medical Coverage Agreement

Outpatient Services. After Deductible, Member pays 20% Plan Coinsurance Injections administered by a Network Provider in a clinical setting during dialysis. Outpatient Services: After Deductible, Member pays 20% Plan Coinsurance Self-administered injectables. See Drugs – Outpatient Prescription for additional pharmacy information. Certain Preventive medications as determined by KFHPWA: Not subject to Deductible. Member pays 20% coinsurance Preferred generic drugs (Tier 1): After Deductible, Member pays ~~$15 Copayment~~ 20% coinsurance per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): After Deductible, Member pays ~~$30 Copayment~~ 20% coinsurance per 30- days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): ~~Not covered;~~ After Deductible, Member pays ~~100~~20% ~~of all charges~~ coinsurance per 30-days up to a 90-day supply Drugs - Outpatient Prescription Prescription drugs, supplies and devices for a supply of 30 days or less including diabetic pharmacy supplies (insulin, lancets, lancet devices, needles, insulin syringes, insulin pens, pen needles and blood glucose test strips), mental health and wellness drugs, self-administered injectables, medications for the treatment arising from sexual assault, and routine costs for prescription medications provided in a clinical trial. “Routine costs” means items and services delivered to the Member that are consistent with and typically covered by the plan or coverage for a Member who is not enrolled in a clinical trial. All drugs, supplies and devices must be for Covered Services. All drugs, supplies and devices must be obtained at a KFHPWA-designated pharmacy except for drugs dispensed for Emergency services or for Emergency services obtained outside of the KFHPWA Service Area including out of the country. Information regarding KFHPWA-designated pharmacies is reflected in the KFHPWA Provider Directory Certain Preventive medications as determined by KFHPWA: Not subject to Deductible. Member pays 20% coinsurance Preferred generic drugs (Tier 1): After Deductible, Member pays 20% coinsurance per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): After Deductible, Member pays 20% coinsurance per 30- days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): After Deductible, Member pays 20% coinsurance per 30-days up to a 90-day supply Annual Deductible does not apply to glucose monitors, test strips, lancets or control solutions. or can be obtained by contacting Xxxxxx Permanente Member Services. Prescription drug Cost Shares are payable at the time of delivery. Certain brand name insulin drugs are covered at the generic drug Cost Share. Preferred generic drugs (Tier 1): After Deductible, Member pays $15 Copayment per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): After Deductible, Member pays $30 Copayment per 30- days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): Not covered; Member pays 100% of all charges Annual Deductible does not apply to glucose monitors, test strips, lancets or control solutions. Note: A Member will not pay more than $100, not subject to the Deductible, for a 30-day supply of insulin to comply with state law requirements. Any cost sharing paid will apply toward the annual Deductible. Members may be eligible to receive an emergency fill for certain prescription drugs filled outside of KFHPWA’s business hours or when KFHPWA cannot reach the prescriber for consultation. For emergency fills, Members pay the prescription drug Cost Share for each 7-day supply or less, or the minimum packaging size available at the time the emergency fill is dispensed. A list of prescription drugs eligible for emergency fills is available on the pharmacy website at xxx.xx.xxx/xx/xxxxxxxxx. Members can request an emergency fill by calling 0-000-000-0000. Certain drugs are subject to Preauthorization as shown in the Preferred drug list (formulary) available at xxx.xx.xxx/xx/xxxxxxxxx. Note: A Member will not pay more than $100, not subject to the Deductible, for a 30-day supply of insulin to comply with state law requirements. Any cost sharing paid will apply toward the annual Deductible. Injections administered by a Network Provider in a clinical setting. After Deductible, Member pays 20% Plan Coinsurance Over-the-counter drugs not included under Preventive Care or Reproductive Health. Not covered; Member pays 100% of all charges Mail order drugs dispensed through the KFHPWA-designated mail order service. Member pays the prescription drug Cost Share for each 30 90 day supply or less Annual Deductible does not apply to glucose monitors, test strips, lancets or control solutions. Note: A Member will not pay more than $100, not subject to the Deductible, for a 30-day supply of insulin to comply with state law requirements. Any cost sharing paid will apply toward the annual Deductible. The KFHPWA Preferred drug list is a list of prescription drugs, supplies, and devices considered to have acceptable efficacy, safety and cost-effectiveness. The Preferred drug list is maintained by a committee consisting of a group of physicians, pharmacists and a consumer representative who review the scientific evidence of these products and determine the Preferred and Non-Preferred status as well as utilization management requirements. Preferred drugs generally have better scientific evidence for safety and effectiveness and are more affordable than Non-Preferred drugs. The preferred drug list is available at xxx.xx.xxx/xx/xxxxxxxxx, or upon request from Member Services. Members may request a coverage determination by contacting Member Services. Coverage determination reviews may include requests to cover non-preferred drugs, obtain Preauthorization for a specific drug, or exceptions to other utilization management requirements, such as quantity limits~~. If coverage of a non-Preferred drug is approved, the drug will be covered at the Preferred drug level~~. Prescription drugs are drugs which have been approved by the Food and Drug Administration (FDA) and which can, under federal or state law, be dispensed only pursuant to a prescription order. These drugs, including off-label use of FDA-approved drugs (provided that such use is documented to be effective in one of the standard reference compendia; a majority of well-designed clinical trials published in peer-reviewed medical literature document improved efficacy or safety of the agent over standard therapies, or over placebo if no standard therapies exist; or by the federal secretary of Health and Human Services) are covered. “Standard reference compendia” means the American Hospital Formulary Service – Drug Information; the American Medical Association Drug Evaluation; the United States Pharmacopoeia – Drug Information, or other authoritative compendia as identified from time to time by the federal secretary of Health and Human Services. “Peer-reviewed medical literature” means scientific studies printed in health care journals or other publications in which original manuscripts are published only after having been critically reviewed for scientific accuracy, validity and reliability by unbiased independent experts. Peer-reviewed medical literature does not include in-house publications of pharmaceutical manufacturing companies. Generic drugs are dispensed whenever available. A generic drug is a drug that is the pharmaceutical equivalent to one or more brand name drugs. Such generic drugs have been approved by the Food and Drug Administration as meeting the same standards of safety, purity, strength and effectiveness as the brand name drug. Brand name drugs are dispensed if there is not a generic equivalent. In the event the Member elects to purchase a brand-name drug instead of the generic equivalent (if available), the Member is responsible for paying the difference in cost in addition to the prescription drug Cost ~~Share~~ Share, which does not apply to the Out-of-pocket Limit. Drug coverage is subject to utilization management that includes Preauthorization, step therapy (when a Member tries a certain medication before receiving coverage for a similar, but non-Preferred medication), limits on drug quantity or days supply and prevention of overutilization, underutilization, therapeutic duplication, drug-drug interactions, incorrect drug dosage, drug-allergy contraindications and clinical abuse/misuse of drugs. If a Member has a new prescription for a chronic condition, the Member may request a coordination of medications so that medications for chronic conditions are refilled on the same schedule (synchronized). Cost-shares for the initial fill of the medication will be adjusted if the fill is less than the standard quantity. Please contact Member Services for more information. Specialty drugs are high-cost drugs prescribed by a physician that requires close supervision and monitoring for serious and/or complex conditions, such as rheumatoid arthritis, hepatitis or multiple sclerosis. Specialty drugs must be obtained through KFHPWA’s preferred specialty pharmacy vendor and/or network of specialty pharmacies and are covered at the appropriate cost share above. For a list of specialty drugs or more information about KFHPWA’s specialty pharmacy network, please go to the KFHPWA website at xxx.xx.xxx/xx/xxxxxxxxx or contact Member Services at ~~206~~000-~~630~~000-~~4636~~ 0000 or toll-free at 10-~~888~~000-~~901~~000-~~4636~~0000. The Member’s Right to Safe and Effective Pharmacy Services: State and federal laws establish standards to assure safe and effective pharmacy services, and to guarantee Members’ right to know what drugs are covered and the coverage limitations. Members who would like more information about the drug coverage policies, or have a question or concern about their pharmacy benefit, may contact KFHPWA at 000-000-0000 or toll-free 10-~~888~~000-~~901~~000-~~4636~~ 0000 or by accessing the KFHPWA website at xxx.xx.xxx/xx. Members who would like to know more about their rights under the law, or think any services received while enrolled may not conform to the terms of the EOC, may contact the Washington State Office of Insurance Commissioner at toll-free 10-~~800~~000-~~562~~000-~~6900~~0000. Members who have a concern about the pharmacists or pharmacies serving them may call the Washington State Department of Health at toll-free 0-000-000-0000. Prescription Drug Coverage and Medicare: This benefit, for purposes of Creditable Coverage, is actuarially equal to or greater than the Medicare Part D prescription drug benefit. Members who are also eligible for Medicare Part D can remain covered and will not be subject to Medicare-imposed late enrollment penalties should they decide to enroll in a Medicare Part D plan at a later date; however, the Member could be subject to payment of higher Part D premiums if the Member subsequently has a break in creditable coverage of 63 continuous days or longer before enrolling in a Part D plan. A Member who discontinues coverage must meet eligibility requirements in order to re- enroll. Exclusions: Over-the-counter drugs, supplies and devices not requiring a prescription under state law or regulations, including most prescription vitamins, except as recommended by the U.S. Preventive Services Task Force (USPSTF); drugs and injections for anticipated illness while traveling; drugs and injections for cosmetic purposes; replacement of lost, stolen, or damaged drugs or devices; administration of excluded drugs and injectables; drugs used in the treatment of sexual dysfunction disorders; compounds which include a non-FDA approved drug; growth hormones for idiopathic short stature without growth hormone deficiency; prescription drugs/products available over-the-counter or have an over-the-counter alternative that is determined to be therapeutically interchangeable Emergency Services Emergency services at a Network Facility or non-Network Facility. See Section XII. for a definition of Emergency. Emergency services include professional services, treatment and supplies, facility costs, outpatient charges for patient observation and medical screening exams required to stabilize a patient. Members must notify KFHPWA by way of the Hospital notification line within 24 hours of any admission, or as soon thereafter as medically possible. If a Member is admitted as an inpatient directly from an emergency department, any Emergency services Copayment is waived. Coverage is subject to the hospital services Cost Share. If a Member is hospitalized in a non-Network Facility, KFHPWA reserves the right to require transfer of the Member to a Network Facility upon consultation between a Network Provider and the attending physician. If the Member refuses to transfer to a Network Facility or does not notify KFHPWA within 24 hours following admission, all further costs incurred during the hospitalization are the responsibility of the Member. Follow-up care which is a direct result of the Emergency must be received from a Network Provider, unless Preauthorization is obtained for such follow-up care from a non-Network Provider. Network Facility: After Deductible, Member pays 20% Plan Coinsurance Non-Network Facility: After Deductible, Member pays 20% Plan Coinsurance Hearing Examinations and Hearing Aids Hearing exams for hearing loss and evaluation are covered only when provided at KFHPWA-approved facilities. Cochlear implants or Bone Anchored Hearing Aids (BAHA) when in accordance with KFHPWA clinical criteria. Covered services for cochlear implants and BAHA include diagnostic testing, pre-implant testing, implant surgery, post- implant follow-up, speech therapy, programming and ~~associated supplies (such as transmitter cable, and batteries).~~ Hospital - Inpatient: After Deductible, Member pays 20% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 20% Plan Coinsurance Outpatient Services: associated supplies (such as transmitter cable, and batteries). After Deductible, Member pays 20% Plan Coinsurance Hearing aids including hearing aid examinations. Member pays nothing, limited to an Allowance of $1,000 maximum per ear per calendar year. After Allowance: Not covered; Member pays 100% of all charges Note: This benefit is separate from the benefits of the Health Savings Account (HSA) Qualified Health Plan and not subject to the annual Deductible Exclusions: Programs or treatments for hearing loss or hearing care including, but not limited to, externally worn hearing or surgically implanted hearing aids and the surgery and services necessary to implant them except as described above; hearing screening tests required under Preventive Services Home Health Care

Appears in 1 contract

Samples: Group Medical Coverage Agreement

Outpatient Services. After Deductible, Member pays 2030% Plan Coinsurance Injections administered by a Network Provider in a clinical setting during dialysis. Outpatient Services: After Deductible, Member pays 2030% Plan Coinsurance Self-administered injectables. See Drugs – Outpatient Prescription for additional pharmacy information. Certain Preventive medications as determined by KFHPWA: Not subject to Deductible. Member pays 30% coinsurance Preferred generic drugs (Tier 1): After Deductible, Member pays ~~$15 Copayment~~ 30% coinsurance per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): After Deductible, Member pays ~~$30 Copayment~~ 30% coinsurance per 30- days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): ~~Not covered;~~ After Deductible, Member pays ~~100~~30% ~~of all charges~~ coinsurance per 30-days up to a 90-day supply Drugs - Outpatient Prescription Prescription drugs, supplies and devices for a supply of 30 days or less including diabetic pharmacy supplies (insulin, lancets, lancet devices, needles, insulin syringes, insulin pens, pen needles and blood glucose test strips), mental health and wellness drugs, self-administered injectables, medications for the treatment arising from sexual assault, and routine costs for prescription medications provided in a clinical trial. “Routine costs” means items and services delivered to the Member that are consistent with and typically covered by the plan or coverage for a Member who is not enrolled in a clinical trial. All drugs, supplies and devices must be for Covered Services. All drugs, supplies and devices must be obtained at a KFHPWA-designated pharmacy except for drugs dispensed for Emergency services or for Emergency services obtained outside of the KFHPWA Service Area including out of the country. Information regarding KFHPWA-designated Certain Preventive medications as determined by KFHPWA: Not subject to Deductible. Member pays 30% coinsurance Preferred generic drugs (Tier 1): After Deductible, Member pays 30% coinsurance per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): After Deductible, Member pays 30% coinsurance per 30- days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): After Deductible, Member pays 30% coinsurance per 30-days up to a 90-day supply pharmacies is reflected in the KFHPWA Provider Directory or can be obtained by contacting Xxxxxx Permanente Member Services. Prescription drug Cost Shares are payable at the time of delivery. Certain brand name insulin drugs are covered at the generic drug Cost Share. Preferred generic drugs (Tier 1): After Deductible, Member pays $15 Copayment per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): After Deductible, Member pays $30 Copayment per 30- days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): Not covered; Member pays 100% of all charges Annual Deductible does not apply to glucose monitors, test strips, lancets or control solutions. Note: A Member will not pay more than $100, not subject to the Deductible, for a 30-day supply of insulin to comply with state law requirements. Any cost sharing paid will apply toward the annual Deductible. Members may be eligible to receive an emergency fill for certain prescription drugs filled outside of KFHPWA’s business hours or when KFHPWA cannot reach the prescriber for consultation. For emergency fills, Members pay the prescription drug Cost Share for each 7-day supply or less, or the minimum packaging size available at the time the emergency fill is dispensed. A list of prescription drugs eligible for emergency fills is available on the pharmacy website at xxx.xx.xxx/xx/xxxxxxxxx. Members can request an emergency fill by calling 0-000-000-0000. Certain drugs are subject to Preauthorization as shown in the Preferred drug list (formulary) available at xxx.xx.xxx/xx/xxxxxxxxx. Annual Deductible does not apply to glucose monitors, test strips, lancets or control solutions. Note: A Member will not pay more than $100, not subject to the Deductible, for a 30-day supply of insulin to comply with state law requirements. Any cost sharing paid will apply toward the annual Deductible. Injections administered by a Network Provider in a clinical setting. After Deductible, Member pays 2030% Plan Coinsurance Over-the-counter drugs not included under Preventive Care or Reproductive Health. Not covered; Member pays 100% of all charges Mail order drugs dispensed through the KFHPWA-designated mail order service. Member pays the prescription drug Cost Share for each 30 90 day supply or less Annual Deductible does not apply to glucose monitors, test strips, lancets or control solutions. Note: A Member will not pay more than $100, not subject to the Deductible, for a 30-day supply of insulin to comply with state law requirements. Any cost sharing paid will apply toward the annual Deductible. The KFHPWA Preferred drug list is a list of prescription drugs, supplies, and devices considered to have acceptable efficacy, safety and cost-effectiveness. The Preferred drug list is maintained by a committee consisting of a group of physicians, pharmacists and a consumer representative who review the scientific evidence of these products and determine the Preferred and Non-Preferred status as well as utilization management requirements. Preferred drugs generally have better scientific evidence for safety and effectiveness and are more affordable than Non-Preferred drugs. The preferred drug list is available at xxx.xx.xxx/xx/xxxxxxxxx, or upon request from Member Services. Members may request a coverage determination by contacting Member Services. Coverage determination reviews may include requests to cover non-preferred drugs, obtain Preauthorization for a specific drug, or exceptions to other utilization management requirements, such as quantity limits~~. If coverage of a non-Preferred drug is approved, the drug will be covered at the Preferred drug level~~. Prescription drugs are drugs which have been approved by the Food and Drug Administration (FDA) and which can, under federal or state law, be dispensed only pursuant to a prescription order. These drugs, including off-label use of FDA-approved drugs (provided that such use is documented to be effective in one of the standard reference compendia; a majority of well-designed clinical trials published in peer-reviewed medical literature document improved efficacy or safety of the agent over standard therapies, or over placebo if no standard therapies exist; or by the federal secretary of Health and Human Services) are covered. “Standard reference compendia” means the American Hospital Formulary Service – Drug Information; the American Medical Association Drug Evaluation; the United States Pharmacopoeia – Drug Information, or other authoritative compendia as identified from time to time by the federal secretary of Health and Human Services. “Peer-reviewed medical literature” means scientific studies printed in health care journals or other publications in which original manuscripts are published only after having been critically reviewed for scientific accuracy, validity and reliability by unbiased independent experts. Peer-reviewed medical literature does not include in-house publications of pharmaceutical manufacturing companies. Generic drugs are dispensed whenever available. A generic drug is a drug that is the pharmaceutical equivalent to one or more brand name drugs. Such generic drugs have been approved by the Food and Drug Administration as meeting the same standards of safety, purity, strength and effectiveness as the brand name drug. Brand name drugs are dispensed if there is not a generic equivalent. In the event the Member elects to purchase a brand-name drug instead of the generic equivalent (if available), the Member is responsible for paying the difference in cost in addition to the prescription drug Cost ~~Share~~ Share, which does not apply to the Out-of-pocket Limit. Drug coverage is subject to utilization management that includes Preauthorization, step therapy (when a Member tries a certain medication before receiving coverage for a similar, but non-Preferred medication), limits on drug quantity or days supply and prevention of overutilization, underutilization, therapeutic duplication, drug-drug interactions, incorrect drug dosage, drug-allergy contraindications and clinical abuse/misuse of drugs. If a Member has a new prescription for a chronic condition, the Member may request a coordination of medications so that medications for chronic conditions are refilled on the same schedule (synchronized). Cost-shares for the initial fill of the medication will be adjusted if the fill is less than the standard quantity. Please contact Member Services for more information. Specialty drugs are high-cost drugs prescribed by a physician that requires close supervision and monitoring for serious and/or complex conditions, such as rheumatoid arthritis, hepatitis or multiple sclerosis. Specialty drugs must be obtained through KFHPWA’s preferred specialty pharmacy vendor and/or network of specialty pharmacies and are covered at the appropriate cost share above. For a list of specialty drugs or more information about KFHPWA’s specialty pharmacy network, please go to the KFHPWA website at xxx.xx.xxx/xx/xxxxxxxxx or contact Member Services at ~~206~~000-~~630~~000-~~4636~~ 0000 or toll-free at 10-~~888~~000-~~901~~000-~~4636~~0000. The Member’s Right to Safe and Effective Pharmacy Services: State and federal laws establish standards to assure safe and effective pharmacy services, and to guarantee Members’ right to know what drugs are covered and the coverage limitations. Members who would like more information about the drug coverage policies, or have a question or concern about their pharmacy benefit, may contact KFHPWA at 000-000-0000 or toll-free 10-~~888~~000-~~901~~000-~~4636~~ 0000 or by accessing the KFHPWA website at xxx.xx.xxx/xx. Members who would like to know more about their rights under the law, or think any services received while enrolled may not conform to the terms of the EOC, may contact the Washington State Office of Insurance Commissioner at toll-free 10-~~800~~000-~~562~~000-~~6900~~0000. Members who have a concern about the pharmacists or pharmacies serving them may call the Washington State Department of Health at toll-free 0-000-000-0000. Prescription Drug Coverage and Medicare: This benefit, for purposes of Creditable Coverage, is actuarially equal to or greater than the Medicare Part D prescription drug benefit. Members who are also eligible for Medicare Part D can remain covered and will not be subject to Medicare-imposed late enrollment penalties should they decide to enroll in a Medicare Part D plan at a later date; however, the Member could be subject to payment of higher Part D premiums if the Member subsequently has a break in creditable coverage of 63 continuous days or longer before enrolling in a Part D plan. A Member who discontinues coverage must meet eligibility requirements in order to re- enroll. Exclusions: Over-the-counter drugs, supplies and devices not requiring a prescription under state law or regulations, including most prescription vitamins, except as recommended by the U.S. Preventive Services Task Force (USPSTF); drugs and injections for anticipated illness while traveling; drugs and injections for cosmetic purposes; replacement of lost, stolen, or damaged drugs or devices; administration of excluded drugs and injectables; drugs used in the treatment of sexual dysfunction disorders; compounds which include a non-FDA approved drug; growth hormones for idiopathic short stature without growth hormone deficiency; prescription drugs/products available over-the-counter or have an over-the-counter alternative that is determined to be therapeutically interchangeable Emergency Services Emergency services at a Network Facility or non-Network Facility. See Section XII. for a definition of Emergency. Emergency services include professional services, treatment and supplies, facility costs, outpatient charges for patient observation and medical screening exams required to stabilize a patient. Members must notify KFHPWA by way of the Hospital notification line within 24 hours of any admission, or as soon thereafter as medically possible. If a Member is admitted as an inpatient directly from an emergency department, any Emergency services Copayment is waived. Coverage is subject to the hospital services Cost Share. If a Member is hospitalized in a non-Network Facility, KFHPWA reserves the right to require transfer of the Member to a Network Facility upon consultation between a Network Provider and the attending physician. If the Member refuses to transfer to a Network Facility or does not notify KFHPWA within 24 hours following admission, all further costs incurred during the hospitalization are the responsibility of the Member. Follow-up care which is a direct result of the Emergency must be received from a Network Provider, unless Preauthorization is obtained for such follow-up care from a non-Network Provider. Network Facility: After Deductible, Member pays 2030% Plan Coinsurance Non-Network Facility: After Deductible, Member pays 2030% Plan Coinsurance Hearing Examinations and Hearing Aids Hearing exams for hearing loss and evaluation are covered only when provided at KFHPWA-approved facilities. Cochlear implants or Bone Anchored Hearing Aids (BAHA) when in accordance with KFHPWA clinical criteria. Covered services for cochlear implants and BAHA include diagnostic testing, pre-implant testing, implant surgery, post- implant follow-up, speech therapy, programming and Hospital - Inpatient: After Deductible, Member pays 30% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 30% Plan Coinsurance associated supplies (such as transmitter cable, and batteries). ~~Hospital - Inpatient: After Deductible, Member pays 20% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 20% Plan Coinsurance~~ Outpatient Services: After Deductible, Member pays 2030% Plan Coinsurance Hearing aids including hearing aid examinations. Member pays nothing, limited to an Allowance of $1,000 maximum per ear per calendar year. After Allowance: Not covered; Member pays 100% of all charges Note: This benefit is separate from the benefits of the Health Savings Account (HSA) Qualified Health Plan and not subject to the annual Deductible Exclusions: Programs or treatments for hearing loss or hearing care including, but not limited to, externally worn hearing or surgically implanted hearing aids and the surgery and services necessary to implant them except as described above; hearing screening tests required under Preventive Services Home Health Care

Appears in 1 contract

Samples: Group Medical Coverage Agreement

Outpatient Services. After Deductible, Member pays 20% Plan Coinsurance Injections administered by a Network Provider in a clinical setting during dialysis. Outpatient Services: After Deductible, Member pays 20% Plan Coinsurance Self-administered injectables. See Drugs – Outpatient Prescription for additional pharmacy information. Preferred generic drugs (Tier 1): After Deductible, Member pays $15 Copayment per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): After Deductible, Member pays $30 Copayment per 30- days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): Not covered; Member pays 100% of all charges Drugs - Outpatient Prescription Prescription drugs, supplies and devices for a supply of 30 days or less including diabetic pharmacy supplies (insulin, lancets, lancet devices, needles, insulin syringes, insulin pens, pen needles and blood glucose test strips), mental health and wellness drugs, self-administered injectables, medications for the treatment arising from sexual assault, and routine costs for prescription medications provided in a clinical trial. “Routine costs” means items and services delivered to the Member that are consistent with and typically covered by the plan or coverage for a Member who is not enrolled in a clinical trial. All drugs, supplies and devices must be for Covered Services. All drugs, supplies and devices must be obtained at a KFHPWA-designated pharmacy except for drugs dispensed for Emergency services or for Emergency services obtained outside of the KFHPWA Service Area including out of the country. Information regarding KFHPWA-designated pharmacies is reflected in the KFHPWA Provider Directory or can be obtained by contacting Xxxxxx Permanente Member Services. Prescription drug Cost Shares are payable at the time of delivery. Certain brand name insulin drugs are covered at the generic drug Cost Share. Preferred generic drugs (Tier 1): After Deductible, Member pays $15 Copayment per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): After Deductible, Member pays $30 Copayment per 30- days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): Not covered; Member pays 100% of all charges Annual Deductible does not apply to glucose monitors, test strips, lancets or control solutions. Note: A Member will not pay more than $100, not subject to the Deductible, for a 30-day supply of insulin to comply with state law requirements. Any cost sharing paid will apply toward the annual Deductible. Members may be eligible to receive an emergency fill for certain prescription drugs filled outside of KFHPWA’s business hours or when KFHPWA cannot reach the prescriber for consultation. For emergency fills, Members pay the prescription drug Cost Share for each 7-day supply or less, or the minimum packaging size available at the time the emergency fill is dispensed. A list of prescription drugs eligible for emergency fills is available on the pharmacy website at xxx.xx.xxx/xx/xxxxxxxxx. Members can request an emergency fill by calling 0-000-000-0000. Certain drugs are subject to Preauthorization as shown in the Preferred drug list (formulary) available at xxx.xx.xxx/xx/xxxxxxxxx. Injections administered by a Network Provider in a clinical setting. After Deductible, Member pays 20% Plan Coinsurance Over-the-counter drugs not included under Preventive Care or Reproductive Health. Not covered; Member pays 100% of all charges Mail order drugs dispensed through the KFHPWA-designated mail order service. Member pays the prescription drug Cost Share for each 30 day supply or less Annual Deductible does not apply to glucose monitors, test strips, lancets or control solutions. Note: A Member will not pay more than $100, not subject to the Deductible, for a 30-day supply of insulin to comply with state law requirements. Any cost sharing paid will apply toward the annual Deductible. The KFHPWA Preferred drug list is a list of prescription drugs, supplies, and devices considered to have acceptable efficacy, safety and cost-effectiveness. The Preferred drug list is maintained by a committee consisting of a group of physicians, pharmacists and a consumer representative who review the scientific evidence of these products and determine the Preferred and Non-Preferred status as well as utilization management requirements. Preferred drugs generally have better scientific evidence for safety and effectiveness and are more affordable than Non-Preferred drugs. The preferred drug list is available at xxx.xx.xxx/xx/xxxxxxxxx, or upon request from Member Services. Members may request a coverage determination by contacting Member Services. Coverage determination reviews may include requests to cover non-preferred drugs, obtain Preauthorization for a specific drug, or exceptions to other utilization management requirements, such as quantity limits. If coverage of a non-Preferred drug is approved, the drug will be covered at the Preferred drug level. Prescription drugs are drugs which have been approved by the Food and Drug Administration (FDA) and which can, under federal or state law, be dispensed only pursuant to a prescription order. These drugs, including off-label use of FDA-approved drugs (provided that such use is documented to be effective in one of the standard reference compendia; a majority of well-designed clinical trials published in peer-reviewed medical literature document improved efficacy or safety of the agent over standard therapies, or over placebo if no standard therapies exist; or by the federal secretary of Health and Human Services) are covered. “Standard reference compendia” means the American Hospital Formulary Service – Drug Information; the American Medical Association Drug Evaluation; the United States Pharmacopoeia – Drug Information, or other authoritative compendia as identified from time to time by the federal secretary of Health and Human Services. “Peer-reviewed medical literature” means scientific studies printed in health care journals or other publications in which original manuscripts are published only after having been critically reviewed for scientific accuracy, validity and reliability by unbiased independent experts. Peer-reviewed medical literature does not include in-house publications of pharmaceutical manufacturing companies. Generic drugs are dispensed whenever available. A generic drug is a drug that is the pharmaceutical equivalent to one or more brand name drugs. Such generic drugs have been approved by the Food and Drug Administration as meeting the same standards of safety, purity, strength and effectiveness as the brand name drug. Brand name drugs are dispensed if there is not a generic equivalent. In the event the Member elects to purchase a brand-name drug instead of the generic equivalent (if available), the Member is responsible for paying the difference in cost in addition to the prescription drug Cost Share which does not apply to the Out-of-pocket Limit. Drug coverage is subject to utilization management that includes Preauthorization, step therapy (when a Member tries a certain medication before receiving coverage for a similar, but non-Preferred medication), limits on drug quantity or days supply and prevention of overutilization, underutilization, therapeutic duplication, drug-drug interactions, incorrect drug dosage, drug-allergy contraindications and clinical abuse/misuse of drugs. If a Member has a new prescription for a chronic condition, the Member may request a coordination of medications so that medications for chronic conditions are refilled on the same schedule (synchronized). Cost-shares for the initial fill of the medication will be adjusted if the fill is less than the standard quantity. Please contact Member Services for more information. Specialty drugs are high-cost drugs prescribed by a physician that requires close supervision and monitoring for serious and/or complex conditions, such as rheumatoid arthritis, hepatitis or multiple sclerosis. Specialty drugs must be obtained through KFHPWA’s preferred specialty pharmacy vendor and/or network of specialty pharmacies and are covered at the appropriate cost share above. For a list of specialty drugs or more information about KFHPWA’s specialty pharmacy network, please go to the KFHPWA website at xxx.xx.xxx/xx/xxxxxxxxx or contact Member Services at ~~206~~000-~~630~~000-~~4636~~ 0000 or toll-free at 10-~~888~~000-~~901~~000-~~4636~~0000. The Member’s Right to Safe and Effective Pharmacy Services: State and federal laws establish standards to assure safe and effective pharmacy services, and to guarantee Members’ right to know what drugs are covered and the coverage limitations. Members who would like more information about the drug coverage policies, or have a question or concern about their pharmacy benefit, may contact KFHPWA at 000-000-0000 or toll-free 10-~~888~~000-~~901~~000-~~4636~~ 0000 or by accessing the KFHPWA website at xxx.xx.xxx/xx. Members who would like to know more about their rights under the law, or think any services received while enrolled may not conform to the terms of the EOC, may contact the Washington State Office of Insurance Commissioner at toll-free 10-~~800~~000-~~562~~000-~~6900~~0000. Members who have a concern about the pharmacists or pharmacies serving them may call the Washington State Department of Health at toll-free 0-000-000-0000. Prescription Drug Coverage and Medicare: This benefit, for purposes of Creditable Coverage, is actuarially equal to or greater than the Medicare Part D prescription drug benefit. Members who are also eligible for Medicare Part D can remain covered and will not be subject to Medicare-imposed late enrollment penalties should they decide to enroll in a Medicare Part D plan at a later date; however, the Member could be subject to payment of higher Part D premiums if the Member subsequently has a break in creditable coverage of 63 continuous days or longer before enrolling in a Part D plan. A Member who discontinues coverage must meet eligibility requirements in order to re- enroll. Exclusions: Over-the-counter drugs, supplies and devices not requiring a prescription under state law or regulations, including most prescription vitamins, except as recommended by the U.S. Preventive Services Task Force (USPSTF); drugs and injections for anticipated illness while traveling; drugs and injections for cosmetic purposes; replacement of lost, stolen, or damaged drugs or devices; administration of excluded drugs and injectables; drugs used in the treatment of sexual dysfunction disorders; compounds which include a non-FDA approved drug; growth hormones for idiopathic short stature without growth hormone deficiency; prescription drugs/products available over-the-counter or have an over-the-counter alternative that is determined to be therapeutically interchangeable Emergency Services Emergency services at a Network Facility or non-Network Facility. See Section XII. for a definition of Emergency. Emergency services include professional services, treatment and supplies, facility costs, outpatient charges for patient observation and medical screening exams required to stabilize a patient. Members must notify KFHPWA by way of the Hospital notification line within 24 hours of any admission, or as soon thereafter as medically possible. If a Member is admitted as an inpatient directly from an emergency department, any Emergency services Copayment is waived. Coverage is subject to the hospital services Cost Share. If a Member is hospitalized in a non-Network Facility, KFHPWA reserves the right to require transfer of the Member to a Network Facility upon consultation between a Network Provider and the attending physician. If the Member refuses to transfer to a Network Facility or does not notify KFHPWA within 24 hours following admission, all further costs incurred during the hospitalization are the responsibility of the Member. Follow-up care which is a direct result of the Emergency must be received from a Network Provider, unless Preauthorization is obtained for such follow-up care from a non-Network Provider. Network Facility: After Deductible, Member pays 20% Plan Coinsurance Non-Network Facility: After Deductible, Member pays 20% Plan Coinsurance Hearing Examinations and Hearing Aids Hearing exams for hearing loss and evaluation are covered only when provided at KFHPWA-approved facilities. Cochlear implants or Bone Anchored Hearing Aids (BAHA) when in accordance with KFHPWA clinical criteria. Covered services for cochlear implants and BAHA include diagnostic testing, pre-implant testing, implant surgery, post- implant follow-up, speech therapy, programming and associated supplies (such as transmitter cable, and batteries). Hospital - Inpatient: After Deductible, Member pays 20% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 20% Plan Coinsurance Outpatient Services: After Deductible, Member pays 20% Plan Coinsurance Hearing aids including hearing aid examinations. Not covered; Member pays 100% of all charges Exclusions: Programs or treatments for hearing loss or hearing care including, but not limited to, externally worn hearing or surgically implanted hearing aids and the surgery and services necessary to implant them except as described above; hearing screening tests required under Preventive Services Home Health Care

Appears in 1 contract

Samples: Group Medical Coverage Agreement

Outpatient Services. After Deductible, Member pays 2010% Plan Coinsurance Enhanced Benefit: After Deductible, Member pays 5% Plan Coinsurance Outpatient Services: After Deductible, Member pays 30% Plan Coinsurance Injections administered by a ~~Network~~ Provider in a clinical setting during dialysis. Outpatient Services: After Deductible, Member pays 2010% Plan Coinsurance Enhanced Benefit: After Deductible, Member pays 5% Plan Coinsurance Outpatient Services: After Deductible, Member pays 30% Plan Coinsurance Self-administered injectables. See Drugs – Outpatient Prescription for additional pharmacy information. Preferred generic drugs (Tier 1): ~~After Deductible,~~ Member pays $15 Copayment up to a 30-day supply Preferred brand name drugs (Tier 2): Member pays $25 Copayment up to a 30-day supply Non-Preferred generic and brand name drugs (Tier 3): Member pays $45 Copayment up to a 30-day supply Enhanced Benefit: Not covered; Member pays 100% of all charges Preferred generic drugs (Tier 1): Member pays $10 Copayment per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): ~~After Deductible,~~ Member pays $30 20 Copayment per ~~30-~~ 30-days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): ~~Not covered;~~ Member pays ~~100% of all charges~~ $40 Copayment per 30- days up to a 90-day supply Drugs - Outpatient Prescription Preferred Provider Network Out-of-Network Prescription drugs, supplies and devices for a supply of 30 days or less including diabetic pharmacy supplies (insulin, lancets, lancet devices, needles, insulin syringes, disposable insulin pens, pen needles and blood glucose test strips), mental health and wellness drugs, self-administered injectables, medications for the treatment arising from sexual assault, and routine costs for prescription medications provided in a clinical trial. “Routine costs” means items and services delivered to the Member that are consistent with and typically covered by the plan or coverage for a Member who is not enrolled in a clinical trial. All drugs, supplies and devices must be for Covered Services. All drugs, supplies and devices must be obtained at a ~~KFHPWA~~KFHPWAO-designated pharmacy except for drugs dispensed for Emergency services or for Emergency services obtained outside of the ~~KFHPWA~~ KFHPWAO Service ~~Area~~ Area, including out of the country. Information regarding ~~KFHPWA~~KFHPWAO-designated pharmacies is are reflected in the ~~KFHPWA~~ KFHPWAO Provider Directory or can be obtained by contacting Xxxxxx Permanente Member Services. Prescription drug Cost Shares are payable at the time of delivery. Certain brand name insulin drugs are covered at the generic drug Cost Share. Certain drugs are subject to Preauthorization as shown in the Preferred drug list (formulary) available at xxx.xx.xxx/xx/xxxxxxxxx. Preferred generic drugs (Tier 1): ~~After Deductible,~~ Member pays $15 Copayment up to a 30-day supply Preferred brand name drugs (Tier 2): Member pays $25 Copayment up to a 30-day supply Non-Preferred generic and brand name drugs (Tier 3): Member pays $45 Copayment up to a 30-day supply Enhanced Benefit: Preferred generic drugs (Tier 1): Member pays $10 Copayment per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): ~~After Deductible,~~ Member pays $30 20 Copayment per ~~30-~~ 30-days up to a 90-day supply ~~Non-Preferred generic and brand name drugs (Tier 3):~~ Not covered; Member pays 100% of all charges Annual Deductible does not apply to glucose monitors, test strips, lancets or control solutions. Note: A Member will not pay more than $100, not subject to the Deductible, for a 30-day supply of insulin to comply with state law requirements. Any cost sharing paid will apply toward the annual Deductible. Members may be eligible to receive an emergency fill for certain prescription drugs filled outside of ~~KFHPWA~~KFHPWAO’s business hours or when ~~KFHPWA~~ KFHPWAO cannot reach the prescriber for consultation. For emergency fills, Members pay the prescription drug Cost Share for each 7-day supply or less, or the minimum packaging size available at the time the emergency fill is dispensed. A list of prescription drugs eligible for emergency fills is available on the pharmacy website at xxx.xx.xxx/xx/xxxxxxxxx. Members can request an emergency fill by calling 0-000-000-0000. ~~Certain drugs~~ In order to obtain the enhanced benefits, Members must utilize designated pharmacies, which are ~~subject to Preauthorization as shown~~ reflected in the KFHPWAO Provider Directory, or can be obtained by contacting Xxxxxx Permanente Member Services. Non-Preferred ~~drug list~~ generic and brand name drugs (~~formulary) available at xxx.xx.xxx/xx/xxxxxxxxx. Injections administered by a Network Provider in a clinical setting. After Deductible,~~ Tier 3): Member pays ~~20% Plan Coinsurance Over~~$40 Copayment per 30- days up to a 90-the-counter drugs not included under Preventive Care or Reproductive Health. Not covered; Member pays 100% of all charges Mail order drugs dispensed through the KFHPWA-designated mail order service. Member pays the prescription drug Cost Share for each 30 day supply ~~or less~~ Annual Deductible does not apply to strip-based blood glucose monitors, test strips, lancets or control ~~solutions.~~ solutions Note: A Member will not pay more than $100, not subject to the Deductible, for a 30-day supply of insulin to comply with state law requirements. Any cost sharing paid will apply toward the annual Deductible. ~~The KFHPWA Preferred drug list is a list of prescription drugs, supplies, and devices considered to have acceptable efficacy, safety and cost-effectiveness. The Preferred drug list is maintained~~ Injections administered by a committee consisting of a group of physicians, pharmacists and a consumer representative who review the scientific evidence of these products and determine the Preferred and Non-Preferred status as well as utilization management requirements. Preferred drugs generally have better scientific evidence for safety and effectiveness and are more affordable than Non-Preferred drugs. The preferred drug list is available at xxx.xx.xxx/xx/xxxxxxxxx, or upon request from Member Services. Members may request a coverage determination by contacting Member Services. Coverage determination reviews may include requests to cover non-preferred drugs, obtain Preauthorization for a specific drug, or exceptions to other utilization management requirements, such as quantity limits. If coverage of a non-Preferred drug is approved, the drug will be covered at the Preferred drug level. Prescription drugs are drugs which have been approved by the Food and Drug Administration (FDA) and which can, under federal or state law, be dispensed only pursuant to a prescription order. These drugs, including off-label use of FDA-approved drugs (provided that such use is documented to be effective in one of the standard reference compendia; a majority of well-designed clinical trials published in peer-reviewed medical literature document improved efficacy or safety of the agent over standard therapies, or over placebo if no standard therapies exist; or by the federal secretary of Health and Human Services) are covered. “Standard reference compendia” means the American Hospital Formulary Service – Drug Information; the American Medical Association Drug Evaluation; the United States Pharmacopoeia – Drug Information, or other authoritative compendia as identified from time to time by the federal secretary of Health and Human Services. “Peer-reviewed medical literature” means scientific studies printed in health care journals or other publications in which original manuscripts are published only after having been critically reviewed for scientific accuracy, validity and reliability by unbiased independent experts. Peer-reviewed medical literature does not include in-house publications of pharmaceutical manufacturing companies. Generic drugs are dispensed whenever available. A generic drug is a drug that is the pharmaceutical equivalent to one or more brand name drugs. Such generic drugs have been approved by the Food and Drug Administration as meeting the same standards of safety, purity, strength and effectiveness as the brand name drug. Brand name drugs are dispensed if there is not a generic equivalent. In the event the Member elects to purchase a brand-name drug instead of the generic equivalent (if available), the Member is responsible for paying the difference in cost in addition to the prescription drug Cost Share which does not apply to the Out-of-pocket Limit. Drug coverage is subject to utilization management that includes Preauthorization, step therapy (when a Member tries a certain medication before receiving coverage for a similar, but non-Preferred medication), limits on drug quantity or days supply and prevention of overutilization, underutilization, therapeutic duplication, drug-drug interactions, incorrect drug dosage, drug-allergy contraindications and clinical abuse/misuse of drugs. If a Member has a new prescription for a chronic condition, the Member may request a coordination of medications so that medications for chronic conditions are refilled on the same schedule (synchronized). Cost-shares for the initial fill of the medication will be adjusted if the fill is less than the standard quantity. Please contact Member Services for more information. Specialty drugs are high-cost drugs prescribed by a physician that requires close supervision and monitoring for serious and/or complex conditions, such as rheumatoid arthritis, hepatitis or multiple sclerosis. Specialty drugs must be obtained through KFHPWA’s preferred specialty pharmacy vendor and/or network of specialty pharmacies and are covered at the appropriate cost share above. For a list of specialty drugs or more information about KFHPWA’s specialty pharmacy network, please go to the KFHPWA website at xxx.xx.xxx/xx/xxxxxxxxx or contact Member Services at 206-630-4636 or toll-free at 1-888-901-4636. The Member’s Right to Safe and Effective Pharmacy Services: State and federal laws establish standards to assure safe and effective pharmacy services, and to guarantee Members’ right to know what drugs are covered and the coverage limitations. Members who would like more information about the drug coverage policies, or have a question or concern about their pharmacy benefit, may contact KFHPWA at 000-000-0000 or toll-free 1-888-901-4636 or by accessing the KFHPWA website at xxx.xx.xxx/xx. Members who would like to know more about their rights under the law, or think any services received while enrolled may not conform to the terms of the EOC, may contact the Washington State Office of Insurance Commissioner at toll-free 1-800-562-6900. Members who have a concern about the pharmacists or pharmacies serving them may call the Washington State Department of Health at toll-free 0-000-000-0000. Prescription Drug Coverage and Medicare: This benefit, for purposes of Creditable Coverage, is actuarially equal to or greater than the Medicare Part D prescription drug benefit. Members who are also eligible for Medicare Part D can remain covered and will not be subject to Medicare-imposed late enrollment penalties should they decide to enroll Provider in a ~~Medicare Part D plan at a later date; however~~clinical setting. After Deductible, ~~the~~ Member could be subject to payment of higher Part D premiums if the Member subsequently has a break in creditable coverage of 63 continuous days or longer before enrolling in a Part D plan. A Member who discontinues coverage must meet eligibility requirements in order to re- enroll. Exclusions: Over-the-counter drugs, supplies and devices not requiring a prescription under state law or regulations, including most prescription vitamins, except as recommended by the U.S. Preventive Services Task Force (USPSTF); drugs and injections for anticipated illness while traveling; drugs and injections for cosmetic purposes; replacement of lost, stolen, or damaged drugs or devices; administration of excluded drugs and injectables; drugs used in the treatment of sexual dysfunction disorders; compounds which include a non-FDA approved drug; growth hormones for idiopathic short stature without growth hormone deficiency; prescription drugs/products available over-the-counter or have an over-the-counter alternative that is determined to be therapeutically interchangeable Emergency Services Emergency services at a Network Facility or non-Network Facility. See Section XII. for a definition of Emergency. Emergency services include professional services, treatment and supplies, facility costs, outpatient charges for patient observation and medical screening exams required to stabilize a patient. Members must notify KFHPWA by way of the Hospital notification line within 24 hours of any admission, or as soon thereafter as medically possible. If a Member is admitted as an inpatient directly from an emergency department, any Emergency services Copayment is waived. Coverage is subject to the hospital services Cost Share. If a Member is hospitalized in a non-Network Facility, KFHPWA reserves the right to require transfer of the Member to a Network Facility upon consultation between a Network Provider and the attending physician. If the Member refuses to transfer to a Network Facility or does not notify KFHPWA within 24 hours following admission, all further costs incurred during the hospitalization are the responsibility of the Member. Follow-up care which is a direct result of the Emergency must be received from a Network Provider, unless Preauthorization is obtained for such follow-up care from a non-Network Provider. Network Facilitypays 10% Plan Coinsurance Enhanced Benefit: After Deductible, Member pays 205% Plan Coinsurance ~~Non-Network Facility:~~ After Deductible, Member pays 2030% Plan Coinsurance ~~Hearing Examinations and Hearing Aids Hearing exams for hearing loss and evaluation are covered only when provided at KFHPWA~~Over-~~approved facilities. Cochlear implants~~ the-counter drugs not included under Preventive Care or Bone Anchored Hearing Aids (BAHA) when in accordance with KFHPWA clinical criteria. Covered services for cochlear implants and BAHA include diagnostic testing, pre-implant testing, implant surgery, post- implant follow-up, speech therapy, programming and associated supplies (such as transmitter cable, and batteries). Hospital - Inpatient: After Deductible, Member pays 20% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 20% Plan Coinsurance Outpatient Services: After Deductible, Member pays 20% Plan Coinsurance Hearing aids including hearing aid examinationsReproductive Health. Not covered; Member pays 100% of all charges ~~Exclusions~~Not covered; Member pays 100% of all charges Mail order drugs dispensed through the KFHPWAO- designated mail order service. Member pays two times the Enhanced Benefit prescription drug Cost Share for each 90-day supply or less Annual Deductible does not apply to strip-based blood glucose monitors, test strips, lancets or control solutions Note: ~~Programs or treatments~~ A Member will Not covered; Member pays 100% of all charges not pay more than $100 for ~~hearing loss or hearing care including, but not limited to, externally worn hearing or surgically implanted hearing aids and the surgery and services necessary~~ a 30-day supply of insulin to ~~implant them except as described above; hearing screening tests required under Preventive Services Home Health Care~~comply with state law requirements.

Appears in 1 contract

Samples: Medical Coverage Agreement

Outpatient Services. After Deductible, Member pays 2010% Plan Coinsurance Enhanced Benefit: After Deductible, Member pays 5% Plan Coinsurance Outpatient Services: After Deductible, Member pays 30% Plan Coinsurance Injections administered by a ~~Network~~ Provider in a clinical setting during dialysis. Outpatient Services: After Deductible, Member pays 2010% Plan Coinsurance Enhanced Benefit: After Deductible, Outpatient Services: After Deductible, Member pays 30% Plan Coinsurance Member pays 5% Plan Coinsurance Self-administered injectables. See Drugs – Outpatient Prescription for additional pharmacy information. Preferred generic drugs (Tier 1): ~~After Deductible,~~ Member pays $15 Copayment up to a 30-day supply Not covered; Member pays 100% of all charges Preferred brand name drugs (Tier 2): Member pays $25 Copayment up to a 30-day supply Non-Preferred generic and brand name drugs (Tier 3): Member pays $45 Copayment up to a 30-day supply Enhanced Benefit: Preferred generic drugs (Tier 1): Member pays $10 Copayment per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): ~~After Deductible,~~ Member pays $30 20 Copayment per ~~30-~~ 30-days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): ~~Not covered;~~ Member pays ~~100% of all charges~~ $40 Copayment per 30- days up to a 90-day supply Drugs - Outpatient Prescription Preferred Provider Network Out-of-Network Prescription drugs, supplies and devices for a supply of 30 days or less including diabetic pharmacy supplies (insulin, lancets, lancet devices, needles, insulin syringes, disposable insulin pens, pen needles and blood glucose test strips), mental health and wellness drugs, self-administered injectables, medications for the treatment arising from sexual assault, and routine costs for prescription medications provided in a clinical trial. “Routine costs” means items and services delivered to the Member that are consistent with and typically covered by the plan or coverage for a Member who Preferred generic drugs (Tier 1): Member pays $15 Copayment up to a 30-day supply Preferred brand name drugs (Tier 2): Member pays $25 Copayment up to a 30-day supply Not covered; Member pays 100% of all charges is not enrolled in a clinical trial. All drugs, supplies and devices must be for Covered Services. All drugs, supplies and devices must be obtained at a ~~KFHPWA~~KFHPWAO-designated pharmacy except for drugs dispensed for Emergency services or for Emergency services obtained outside of the ~~KFHPWA~~ KFHPWAO Service ~~Area~~ Area, including out of the country. Information regarding ~~KFHPWA~~KFHPWAO-designated pharmacies is are reflected in the ~~KFHPWA~~ KFHPWAO Provider Directory or can be obtained by contacting Xxxxxx Permanente Member Services. Prescription drug Cost Shares are payable at the time of delivery. Certain brand name insulin drugs are covered at the generic drug Cost Share. ~~Preferred generic~~ Certain drugs (Tier 1): After Deductible, Member pays $15 Copayment per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): After Deductible, Member pays $30 Copayment per 30- days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): Not covered; Member pays 100% of all charges Annual Deductible does not apply to glucose monitors, test strips, lancets or control solutions. Note: A Member will not pay more than $100, not are subject to Preauthorization as shown in the ~~Deductible, for a 30-day supply of insulin to comply with state law requirements. Any cost sharing paid will apply toward the annual Deductible~~Preferred drug list (formulary) available at xxx.xx.xxx/xx/xxxxxxxxx. Members may be eligible to receive an emergency fill for certain prescription drugs filled outside of ~~KFHPWA~~KFHPWAO’s business hours or when ~~KFHPWA~~ KFHPWAO cannot reach the prescriber for consultation. For emergency fills, Members pay the prescription drug Cost Share for each 7-day supply or less, or the minimum packaging size available at the time the emergency fill is dispensed. A list of prescription drugs eligible for emergency fills is available on the pharmacy website at xxx.xx.xxx/xx/xxxxxxxxx. Members can request an emergency fill by calling 0-000-000-0000. ~~Certain drugs~~ In order to obtain the enhanced benefits, Members must utilize designated pharmacies, which are ~~subject to Preauthorization as shown~~ reflected in the KFHPWAO Provider Directory, or can be obtained by contacting Xxxxxx Permanente Member Services. For outpatient prescription drugs and/or items that are covered under the Drugs – Outpatient Prescription section and obtained at a pharmacy owned and operated by KFHPWA, a Member may be able to use approved manufacturer coupons as payment for the Cost Sharing that a Member owes, as allowed under KFHPWA’s coupon program. A Member will owe any additional amount if the coupon does not cover the entire amount of the Cost Sharing for the Member’s prescription. When a Member uses an approved coupon for payment of their Cost Sharing, the coupon amount and any additional payment that you make will accumulate to their Out-of-Pocket Limit. More information is available regarding the Xxxxxx Permanente coupon program rules and limitations at xx.xxx/xxxxxxxxx. Non-Preferred ~~drug list~~ generic and brand name drugs (~~formulary) available at xxx.xx.xxx/xx/xxxxxxxxx. Injections administered by a Network Provider in a clinical setting. After Deductible,~~ Tier 3): Member pays ~~20% Plan Coinsurance Over~~$45 Copayment up to a 30-~~the-counter~~ day supply Enhanced Benefit: Preferred generic drugs ~~not included under Preventive Care or Reproductive Health. Not covered;~~ (Tier 1): Member pays ~~100% of all charges Mail order~~ $10 Copayment per 30-days up to a 90-day supply Preferred brand name drugs ~~dispensed through the KFHPWA-designated mail order service.~~ (Tier 2): Member pays ~~the prescription drug Cost Share for each 30~~ $20 Copayment per 30-days up to a 90-day supply ~~or less~~ Non-Preferred generic and brand name drugs (Tier 3): Member pays $40 Copayment per 30- days up to a 90-day supply Annual Deductible does not apply to strip-based blood glucose monitors, test strips, lancets or control ~~solutions.~~ solutions Note: A Member will not pay more than $~~100~~35, not subject to the Deductible, for a 30-day supply of insulin to comply with state law requirements. Any cost sharing paid will apply toward the annual Deductible. ~~The KFHPWA Preferred drug list is a list of prescription drugs, supplies, and devices considered to have acceptable efficacy, safety and cost-effectiveness. The Preferred drug list is maintained~~ Injections administered by a committee consisting of a group of physicians, pharmacists and a consumer representative who review the scientific evidence of these products and determine the Preferred and Non-Preferred status as well as utilization management requirements. Preferred drugs generally have better scientific evidence for safety and effectiveness and are more affordable than Non-Preferred drugs. The preferred drug list is available at xxx.xx.xxx/xx/xxxxxxxxx, or upon request from Member Services. Members may request a coverage determination by contacting Member Services. Coverage determination reviews may include requests to cover non-preferred drugs, obtain Preauthorization for a specific drug, or exceptions to other utilization management requirements, such as quantity limits. If coverage of a non-Preferred drug is approved, the drug will be covered at the Preferred drug level. Prescription drugs are drugs which have been approved by the Food and Drug Administration (FDA) and which can, under federal or state law, be dispensed only pursuant to a prescription order. These drugs, including off-label use of FDA-approved drugs (provided that such use is documented to be effective in one of the standard reference compendia; a majority of well-designed clinical trials published in peer-reviewed medical literature document improved efficacy or safety of the agent over standard therapies, or over placebo if no standard therapies exist; or by the federal secretary of Health and Human Services) are covered. “Standard reference compendia” means the American Hospital Formulary Service – Drug Information; the American Medical Association Drug Evaluation; the United States Pharmacopoeia – Drug Information, or other authoritative compendia as identified from time to time by the federal secretary of Health and Human Services. “Peer-reviewed medical literature” means scientific studies printed in health care journals or other publications in which original manuscripts are published only after having been critically reviewed for scientific accuracy, validity and reliability by unbiased independent experts. Peer-reviewed medical literature does not include in-house publications of pharmaceutical manufacturing companies. Generic drugs are dispensed whenever available. A generic drug is a drug that is the pharmaceutical equivalent to one or more brand name drugs. Such generic drugs have been approved by the Food and Drug Administration as meeting the same standards of safety, purity, strength and effectiveness as the brand name drug. Brand name drugs are dispensed if there is not a generic equivalent. In the event the Member elects to purchase a brand-name drug instead of the generic equivalent (if available), the Member is responsible for paying the difference in cost in addition to the prescription drug Cost Share which does not apply to the Out-of-pocket Limit. Drug coverage is subject to utilization management that includes Preauthorization, step therapy (when a Member tries a certain medication before receiving coverage for a similar, but non-Preferred medication), limits on drug quantity or days supply and prevention of overutilization, underutilization, therapeutic duplication, drug-drug interactions, incorrect drug dosage, drug-allergy contraindications and clinical abuse/misuse of drugs. If a Member has a new prescription for a chronic condition, the Member may request a coordination of medications so that medications for chronic conditions are refilled on the same schedule (synchronized). Cost-shares for the initial fill of the medication will be adjusted if the fill is less than the standard quantity. Please contact Member Services for more information. Specialty drugs are high-cost drugs prescribed by a physician that requires close supervision and monitoring for serious and/or complex conditions, such as rheumatoid arthritis, hepatitis or multiple sclerosis. Specialty drugs must be obtained through KFHPWA’s preferred specialty pharmacy vendor and/or network of specialty pharmacies and are covered at the appropriate cost share above. For a list of specialty drugs or more information about KFHPWA’s specialty pharmacy network, please go to the KFHPWA website at xxx.xx.xxx/xx/xxxxxxxxx or contact Member Services at 206-630-4636 or toll-free at 1-888-901-4636. The Member’s Right to Safe and Effective Pharmacy Services: State and federal laws establish standards to assure safe and effective pharmacy services, and to guarantee Members’ right to know what drugs are covered and the coverage limitations. Members who would like more information about the drug coverage policies, or have a question or concern about their pharmacy benefit, may contact KFHPWA at 000-000-0000 or toll-free 1-888-901-4636 or by accessing the KFHPWA website at xxx.xx.xxx/xx. Members who would like to know more about their rights under the law, or think any services received while enrolled may not conform to the terms of the EOC, may contact the Washington State Office of Insurance Commissioner at toll-free 1-800-562-6900. Members who have a concern about the pharmacists or pharmacies serving them may call the Washington State Department of Health at toll-free 0-000-000-0000. Prescription Drug Coverage and Medicare: This benefit, for purposes of Creditable Coverage, is actuarially equal to or greater than the Medicare Part D prescription drug benefit. Members who are also eligible for Medicare Part D can remain covered and will not be subject to Medicare-imposed late enrollment penalties should they decide to enroll Provider in a ~~Medicare Part D plan at a later date; however~~clinical setting. After Deductible, ~~the~~ Member ~~could be subject to payment of higher Part D premiums if the~~ pays 10% Plan Coinsurance After Deductible, Member subsequently has a break in creditable coverage of 63 continuous days or longer before enrolling in a Part D plan. A Member who discontinues coverage must meet eligibility requirements in order to re- enroll. Exclusions: Over-the-counter drugs, supplies and devices not requiring a prescription under state law or regulations, including most prescription vitamins, except as recommended by the U.S. Preventive Services Task Force (USPSTF); drugs and injections for anticipated illness while traveling; drugs and injections for cosmetic purposes; replacement of lost, stolen, or damaged drugs or devices; administration of excluded drugs and injectables; drugs used in the treatment of sexual dysfunction disorders; compounds which include a non-FDA approved drug; growth hormones for idiopathic short stature without growth hormone deficiency; prescription drugs/products available over-the-counter or have an over-the-counter alternative that is determined to be therapeutically interchangeable Emergency Services Emergency services at a Network Facility or non-Network Facility. See Section XII. for a definition of Emergency. Emergency services include professional services, treatment and supplies, facility costs, outpatient charges for patient observation and medical screening exams required to stabilize a patient. Members must notify KFHPWA by way of the Hospital notification line within 24 hours of any admission, or as soon thereafter as medically possible. If a Member is admitted as an inpatient directly from an emergency department, any Emergency services Copayment is waived. Coverage is subject to the hospital services Cost Share. If a Member is hospitalized in a non-Network Facility, KFHPWA reserves the right to require transfer of the Member to a Network Facility upon consultation between a Network Provider and the attending physician. If the Member refuses to transfer to a Network Facility or does not notify KFHPWA within 24 hours following admission, all further costs incurred during the hospitalization are the responsibility of the Member. Follow-up care which is a direct result of the Emergency must be received from a Network Provider, unless Preauthorization is obtained for such follow-up care from a non-Network Provider. Network Facilitypays 30% Plan Coinsurance Enhanced Benefit: After Deductible, Member pays 205% Plan Coinsurance ~~Non~~Over-~~Network Facility: After Deductible, Member pays 20% Plan Coinsurance Hearing Examinations and Hearing Aids Hearing exams for hearing loss and evaluation are covered only when provided at KFHPWA~~the-~~approved facilities. Cochlear implants~~ counter drugs not included under Preventive Care or Bone Anchored Hearing Aids (BAHA) when in accordance with KFHPWA clinical criteria. Covered services for cochlear implants and BAHA include diagnostic testing, pre-implant testing, implant surgery, post- implant follow-up, speech therapy, programming and associated supplies (such as transmitter cable, and batteries). Hospital - Inpatient: After Deductible, Member pays 20% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 20% Plan Coinsurance Outpatient Services: After Deductible, Member pays 20% Plan Coinsurance Hearing aids including hearing aid examinationsReproductive Health. Not covered; Member pays 100% of all charges ~~Exclusions~~Not covered; Member pays 100% of all charges Mail order drugs dispensed through the KFHPWAO- designated mail order service. Member pays two times the Enhanced Benefit prescription drug Cost Share for each 90-day supply or less Annual Deductible does not apply to strip-based blood glucose monitors, test strips, lancets or control solutions Note: ~~Programs or treatments~~ A Member will not pay more than $35 for ~~hearing loss or hearing care including, but not limited to, externally worn hearing or surgically implanted hearing aids and the surgery and services necessary~~ a 30-day supply of insulin to ~~implant them except as described above~~comply with state law requirements. Not covered; ~~hearing screening tests required under Preventive Services Home Health Care~~Member pays 100% of all charges

Appears in 1 contract

Samples: Medical Coverage Agreement

Outpatient Services. After Deductible, Member pays 2030% Plan Coinsurance Injections administered by a Network Provider in a clinical setting during dialysis. Outpatient Services: After Deductible, Member pays 2030% Plan Coinsurance Self-administered injectables. See Drugs – Outpatient Prescription for additional pharmacy information. Certain Preventive medications as determined by KFHPWA: Not subject to Deductible. Member pays 30% coinsurance Preferred generic drugs (Tier 1): After Deductible, Member pays ~~$15 Copayment~~ 30% coinsurance per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): After Deductible, Member pays ~~$30 Copayment~~ 30% coinsurance per 30- days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): ~~Not covered;~~ After Deductible, Member pays ~~100~~30% ~~of all charges~~ coinsurance per 30-days up to a 90-day supply Drugs - Outpatient Prescription Prescription drugs, supplies and devices for a supply of 30 days or less including diabetic pharmacy supplies (insulin, lancets, lancet devices, needles, insulin syringes, insulin pens, pen needles and blood glucose test strips), mental health and wellness drugs, self-administered injectables, medications for the treatment arising from sexual assault, and routine costs for prescription medications provided in a clinical trial. “Routine costs” means items and services delivered to the Member that are consistent with and typically covered by the plan or coverage for a Member who is not enrolled in a clinical trial. All drugs, supplies and devices must be for Covered Services. All drugs, supplies and devices must be obtained at a KFHPWA-designated pharmacy except for drugs dispensed for Emergency services or for Emergency services obtained outside of the KFHPWA Service Area including out of the country. Information regarding KFHPWA-designated Certain Preventive medications as determined by KFHPWA: Not subject to Deductible. Member pays 30% coinsurance Preferred generic drugs (Tier 1): After Deductible, Member pays 30% coinsurance per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): After Deductible, Member pays 30% coinsurance per 30- days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): After Deductible, Member pays 30% coinsurance per 30-days up to a 90-day supply pharmacies is reflected in the KFHPWA Provider Directory or can be obtained by contacting Xxxxxx Permanente Member Services. Prescription drug Cost Shares are payable at the time of delivery. Certain brand name insulin drugs are covered at the generic drug Cost Share. Preferred generic drugs (Tier 1): After Deductible, Member pays $15 Copayment per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): After Deductible, Member pays $30 Copayment per 30- days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): Not covered; Member pays 100% of all charges Annual Deductible does not apply to glucose monitors, test strips, lancets or control solutions. Note: A Member will not pay more than $100, not subject to the Deductible, for a 30-day supply of insulin to comply with state law requirements. Any cost sharing paid will apply toward the annual Deductible. Members may be eligible to receive an emergency fill for certain prescription drugs filled outside of KFHPWA’s business hours or when KFHPWA cannot reach the prescriber for consultation. For emergency fills, Members pay the prescription drug Cost Share for each 7-day supply or less, or the minimum packaging size available at the time the emergency fill is dispensed. A list of prescription drugs eligible for emergency fills is available on the pharmacy website at xxx.xx.xxx/xx/xxxxxxxxx. Members can request an emergency fill by calling 0-000-000-0000. Certain drugs are subject to Preauthorization as shown in the Preferred drug list (formulary) available at xxx.xx.xxx/xx/xxxxxxxxx. Annual Deductible does not apply to glucose monitors, test strips, lancets or control solutions. Note: A Member will not pay more than $100, not subject to the Deductible, for a 30-day supply of insulin to comply with state law requirements. Any cost sharing paid will apply toward the annual Deductible. Injections administered by a Network Provider in a clinical setting. After Deductible, Member pays 2030% Plan Coinsurance Over-the-counter drugs not included under Preventive Care or Reproductive Health. Not covered; Member pays 100% of all charges Mail order drugs dispensed through the KFHPWA-designated mail order service. Member pays the prescription drug Cost Share for each 30 90 day supply or less Annual Deductible does not apply to glucose monitors, test strips, lancets or control solutions. Note: A Member will not pay more than $100, not subject to the Deductible, for a 30-day supply of insulin to comply with state law requirements. Any cost sharing paid will apply toward the annual Deductible. The KFHPWA Preferred drug list is a list of prescription drugs, supplies, and devices considered to have acceptable efficacy, safety and cost-effectiveness. The Preferred drug list is maintained by a committee consisting of a group of physicians, pharmacists and a consumer representative who review the scientific evidence of these products and determine the Preferred and Non-Preferred status as well as utilization management requirements. Preferred drugs generally have better scientific evidence for safety and effectiveness and are more affordable than Non-Preferred drugs. The preferred drug list is available at xxx.xx.xxx/xx/xxxxxxxxx, or upon request from Member Services. Members may request a coverage determination by contacting Member Services. Coverage determination reviews may include requests to cover non-preferred drugs, obtain Preauthorization for a specific drug, or exceptions to other utilization management requirements, such as quantity limits~~. If coverage of a non-Preferred drug is approved, the drug will be covered at the Preferred drug level~~. Prescription drugs are drugs which have been approved by the Food and Drug Administration (FDA) and which can, under federal or state law, be dispensed only pursuant to a prescription order. These drugs, including off-label use of FDA-approved drugs (provided that such use is documented to be effective in one of the standard reference compendia; a majority of well-designed clinical trials published in peer-reviewed medical literature document improved efficacy or safety of the agent over standard therapies, or over placebo if no standard therapies exist; or by the federal secretary of Health and Human Services) are covered. “Standard reference compendia” means the American Hospital Formulary Service – Drug Information; the American Medical Association Drug Evaluation; the United States Pharmacopoeia – Drug Information, or other authoritative compendia as identified from time to time by the federal secretary of Health and Human Services. “Peer-reviewed medical literature” means scientific studies printed in health care journals or other publications in which original manuscripts are published only after having been critically reviewed for scientific accuracy, validity and reliability by unbiased independent experts. Peer-reviewed medical literature does not include in-house publications of pharmaceutical manufacturing companies. Generic drugs are dispensed whenever available. A generic drug is a drug that is the pharmaceutical equivalent to one or more brand name drugs. Such generic drugs have been approved by the Food and Drug Administration as meeting the same standards of safety, purity, strength and effectiveness as the brand name drug. Brand name drugs are dispensed if there is not a generic equivalent. In the event the Member elects to purchase a brand-name drug instead of the generic equivalent (if available), the Member is responsible for paying the difference in cost in addition to the prescription drug Cost ~~Share~~ Share, which does not apply to the Out-of-pocket Limit. Drug coverage is subject to utilization management that includes Preauthorization, step therapy (when a Member tries a certain medication before receiving coverage for a similar, but non-Preferred medication), limits on drug quantity or days supply and prevention of overutilization, underutilization, therapeutic duplication, drug-drug interactions, incorrect drug dosage, drug-allergy contraindications and clinical abuse/misuse of drugs. If a Member has a new prescription for a chronic condition, the Member may request a coordination of medications so that medications for chronic conditions are refilled on the same schedule (synchronized). Cost-shares for the initial fill of the medication will be adjusted if the fill is less than the standard quantity. Please contact Member Services for more information. Specialty drugs are high-cost drugs prescribed by a physician that requires close supervision and monitoring for serious and/or complex conditions, such as rheumatoid arthritis, hepatitis or multiple sclerosis. Specialty drugs must be obtained through KFHPWA’s preferred specialty pharmacy vendor and/or network of specialty pharmacies and are covered at the appropriate cost share above. For a list of specialty drugs or more information about KFHPWA’s specialty pharmacy network, please go to the KFHPWA website at xxx.xx.xxx/xx/xxxxxxxxx or contact Member Services at 206-630-4636 or toll-free at 1-888-901-4636. The Member’s Right to Safe and Effective Pharmacy Services: State and federal laws establish standards to assure safe and effective pharmacy services, and to guarantee Members’ right to know what drugs are covered and the coverage limitations. Members who would like more information about the drug coverage policies, or have a question or concern about their pharmacy benefit, may contact KFHPWA at 000-000-0000 or toll-free 1-888-901-4636 or by accessing the KFHPWA website at xxx.xx.xxx/xx. Members who would like to know more about their rights under the law, or think any services received while enrolled may not conform to the terms of the EOC, may contact the Washington State Office of Insurance Commissioner at toll-free 1-800-562-6900. Members who have a concern about the pharmacists or pharmacies serving them may call the Washington State Department of Health at toll-free 0-000-000-0000. Prescription Drug Coverage and Medicare: This benefit, for purposes of Creditable Coverage, is actuarially equal to or greater than the Medicare Part D prescription drug benefit. Members who are also eligible for Medicare Part D can remain covered and will not be subject to Medicare-imposed late enrollment penalties should they decide to enroll in a Medicare Part D plan at a later date; however, the Member could be subject to payment of higher Part D premiums if the Member subsequently has a break in creditable coverage of 63 continuous days or longer before enrolling in a Part D plan. A Member who discontinues coverage must meet eligibility requirements in order to re- enroll. Exclusions: Over-the-counter drugs, supplies and devices not requiring a prescription under state law or regulations, including most prescription vitamins, except as recommended by the U.S. Preventive Services Task Force (USPSTF); drugs and injections for anticipated illness while traveling; drugs and injections for cosmetic purposes; replacement of lost, stolen, or damaged drugs or devices; administration of excluded drugs and injectables; drugs used in the treatment of sexual dysfunction disorders; compounds which include a non-FDA approved drug; growth hormones for idiopathic short stature without growth hormone deficiency; prescription drugs/products available over-the-counter or have an over-the-counter alternative that is determined to be therapeutically interchangeable Emergency Services Emergency services at a Network Facility or non-Network Facility. See Section XII. for a definition of Emergency. Emergency services include professional services, treatment and supplies, facility costs, outpatient charges for patient observation and medical screening exams required to stabilize a patient. Members must notify KFHPWA by way of the Hospital notification line within 24 hours of any admission, or as soon thereafter as medically possible. If a Member is admitted as an inpatient directly from an emergency department, any Emergency services Copayment is waived. Coverage is subject to the hospital services Cost Share. If a Member is hospitalized in a non-Network Facility, KFHPWA reserves the right to require transfer of the Member to a Network Facility upon consultation between a Network Provider and the attending physician. If the Member refuses to transfer to a Network Facility or does not notify KFHPWA within 24 hours following admission, all further costs incurred during the hospitalization are the responsibility of the Member. Follow-up care which is a direct result of the Emergency must be received from a Network Provider, unless Preauthorization is obtained for such follow-up care from a non-Network Provider. Network Facility: After Deductible, Member pays 2030% Plan Coinsurance Non-Network Facility: After Deductible, Member pays 2030% Plan Coinsurance Hearing Examinations and Hearing Aids Hearing exams for hearing loss and evaluation are covered only when provided at KFHPWA-approved facilities. Cochlear implants or Bone Anchored Hearing Aids (BAHA) when in accordance with KFHPWA clinical criteria. Covered services for cochlear implants and BAHA include diagnostic testing, pre-implant testing, implant surgery, post- implant follow-up, speech therapy, programming and Hospital - Inpatient: After Deductible, Member pays 30% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 30% Plan Coinsurance associated supplies (such as transmitter cable, and batteries). ~~Hospital - Inpatient: After Deductible, Member pays 20% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 20% Plan Coinsurance~~ Outpatient Services: After Deductible, Member pays 2030% Plan Coinsurance Hearing aids including hearing aid examinations. Member pays nothing, limited to an Allowance of $1,000 maximum per ear per calendar year. After Allowance: Not covered; Member pays 100% of all charges Note: This benefit is separate from the benefits of the Health Savings Account (HSA) Qualified Health Plan and not subject to the annual Deductible Exclusions: Programs or treatments for hearing loss or hearing care including, but not limited to, externally worn hearing or surgically implanted hearing aids and the surgery and services necessary to implant them except as described above; hearing screening tests required under Preventive Services Home Health Care

Appears in 1 contract

Samples: Group Medical Coverage Agreement

Outpatient Services. After Deductible, Member pays ~~20% Plan Coinsurance~~ $10 Copayment for primary care provider services or $20 Copayment for specialty care provider services Injections administered by a ~~Network Provider~~ professional in a clinical setting during dialysis. Outpatient Services: After Deductible, Member pays ~~20% Plan Coinsurance~~ $10 Copayment for primary care provider services or $20 Copayment for specialty care provider services Self-administered injectables. See Drugs – Outpatient Prescription for additional pharmacy information. Preferred generic drugs (Tier 1): ~~After Deductible,~~ Member pays $15 5 Copayment ~~per 30-days up to a 90-day supply~~ Preferred brand name drugs (Tier 2): ~~After Deductible,~~ Member pays $30 25 Copayment ~~per 30- days up to a 90-day supply~~ Non-Preferred generic and brand name drugs (Tier 3): ~~Not covered;~~ Member pays ~~100% of all charges~~ $50 Copayment Drugs - Outpatient Prescription Prescription drugs, supplies and devices for a supply of 30 days or less including diabetic pharmacy supplies (insulin, lancets, lancet devices, needles, insulin syringes, insulin pens, pen needles and blood glucose test strips), mental health ~~and wellness~~ drugs, self-administered injectables~~, medications for the treatment arising from sexual assault~~, and routine costs for prescription medications provided in a clinical trial. “Routine costs” means items and services delivered to the Member that are consistent with and typically covered by the plan or coverage for a Member who is not enrolled in a clinical trial. All drugs, supplies and devices must be for Covered Services. All drugs, supplies and devices must be obtained at a KFHPWA-designated pharmacy except for drugs dispensed for Emergency services or for Emergency services obtained outside of the KFHPWA Service ~~Area~~ Area, including out of the country. Information regarding KFHPWA-designated pharmacies is reflected in the KFHPWA Provider Directory or can be obtained by contacting Xxxxxx Permanente Member Services. Prescription drug Cost Shares are payable at the time of delivery. Certain brand name insulin drugs are covered at the generic drug Cost Share. Preferred generic drugs (Tier 1): After Deductible, Member pays $15 Copayment per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): After Deductible, Member pays $30 Copayment per 30- days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): Not covered; Member pays 100% of all charges Annual Deductible does not apply to glucose monitors, test strips, lancets or control solutions. Note: A Member will not pay more than $100, not subject to the Deductible, for a 30-day supply of insulin to comply with state law requirements. Any cost sharing paid will apply toward the annual Deductible. Members may be eligible to receive an emergency fill for certain prescription drugs filled outside of KFHPWA’s business hours or when KFHPWA cannot reach the prescriber for consultation. For emergency fills, Members pay the Preferred generic drugs (Tier 1): Member pays $5 Copayment Preferred brand name drugs (Tier 2): Member pays $25 Copayment Non-Preferred generic and brand name drugs (Tier 3): Member pays $50 Copayment prescription drug Cost Share for each 7-day supply or less, or the minimum packaging size available at the time the emergency fill is dispensed. A list of prescription drugs eligible for emergency fills is available on the pharmacy website at xxx.xx.xxx/xx/xxxxxxxxx. Members can request an emergency fill by calling 0-000-000-0000. Certain drugs are subject to Preauthorization as shown in the Preferred drug list (formulary) available at xxx.xx.xxx/xx/xxxxxxxxx. Injections administered by a ~~Network Provider~~ professional in a clinical setting. After Deductible, Member pays ~~20% Plan Coinsurance~~ $10 Copayment for primary care provider services or $20 Copayment for specialty care provider services Over-the-counter drugs not included under Preventive Care or Reproductive Health. Not covered; Member pays 100% of all charges Mail order drugs dispensed through the KFHPWA-designated mail order service. Member pays two times the prescription drug Cost Share for each 30 90 day supply or less Annual Deductible does not apply to glucose monitors, test strips, lancets or control solutions. Note: A Member will not pay more than $100, not subject to the Deductible, for a 30-day supply of insulin to comply with state law requirements. Any cost sharing paid will apply toward the annual Deductible. The KFHPWA Preferred drug list is a list of prescription drugs, supplies, and devices considered to have acceptable efficacy, safety and cost-effectiveness. The Preferred drug list is maintained by a committee consisting of a group of physicians, pharmacists and a consumer representative who review the scientific evidence of these products and determine the Preferred and Non-Preferred status as well as utilization management requirements. Preferred drugs generally have better scientific evidence for safety and effectiveness and are more affordable than Non-Preferred drugs. The preferred drug list is available at xxx.xx.xxx/xx/xxxxxxxxx, or upon request from Member Services. Members may request a coverage determination by contacting Member Services. Coverage determination reviews may include requests to cover non-preferred drugs, obtain Preauthorization for a specific drug, or exceptions to other utilization management requirements, such as quantity limits. If coverage of a non-Preferred drug is approved, the drug will be covered at the Preferred drug level. Prescription drugs are drugs which have been approved by the Food and Drug Administration (FDA) and which can, under federal or state law, be dispensed only pursuant to a prescription order. These drugs, including off-label use of FDA-approved drugs (provided that such use is documented to be effective in one of the standard reference compendia; a majority of well-designed clinical trials published in peer-reviewed medical literature document improved efficacy or safety of the agent over standard therapies, or over placebo if no standard therapies exist; or by the federal secretary of Health and Human Services) are covered. “Standard reference compendia” means the American Hospital Formulary Service – Drug Information; the American Medical Association Drug Evaluation; the United States Pharmacopoeia – Drug Information, or other authoritative compendia as identified from time to time by the federal secretary of Health and Human Services. “Peer-reviewed medical literature” means scientific studies printed in health care journals or other publications in which original manuscripts are published only after having been critically reviewed for scientific accuracy, validity and reliability by unbiased independent experts. Peer-reviewed medical literature does not include in-house publications of pharmaceutical manufacturing companies. Generic drugs are dispensed whenever available. A generic drug is a drug that is the pharmaceutical equivalent to one or more brand name drugs. Such generic drugs have been approved by the Food and Drug Administration as meeting the same standards of safety, purity, strength and effectiveness as the brand name drug. Brand name drugs are dispensed if there is not a generic equivalent. In the event the Member elects to purchase a brand-name drug instead of the generic equivalent (if available), the Member is responsible for paying the difference in cost in addition to the prescription drug Cost Share which does not apply to the Out-of-pocket Limit. Drug coverage is subject to utilization management that includes Preauthorization, step therapy (when a Member tries a certain medication before receiving coverage for a similar, but non-Preferred medication), limits on drug quantity or days supply and prevention of overutilization, underutilization, therapeutic duplication, drug-drug interactions, incorrect drug dosage, drug-allergy contraindications and clinical abuse/misuse of drugs. If a Member has a new prescription for a chronic condition, the Member may request a coordination of medications so that medications for chronic conditions are refilled on the same schedule (synchronized). Cost-shares for the initial fill of the medication will be adjusted if the fill is less than the standard quantity. Please contact Member Services for more information. Specialty drugs are high-cost drugs prescribed by a physician that requires close supervision and monitoring for serious and/or complex conditions, such as rheumatoid arthritis, hepatitis or multiple sclerosis. Specialty drugs must be obtained through KFHPWA’s preferred specialty pharmacy vendor and/or network of specialty pharmacies and are covered at the appropriate cost share above. For a list of specialty drugs or more information about KFHPWA’s specialty pharmacy network, please go to the KFHPWA website at xxx.xx.xxx/xx/xxxxxxxxx or contact Member Services at 206-630-4636 or toll-free at 1-888-901-4636. The Member’s Right to Safe and Effective Pharmacy Services: State and federal laws establish standards to assure safe and effective pharmacy services, and to guarantee Members’ right to know what drugs are covered and the coverage limitations. Members who would like more information about the drug coverage policies, or have a question or concern about their pharmacy benefit, may contact KFHPWA at 000-000-0000 or toll-free 1-888-901-4636 or by accessing the KFHPWA website at xxx.xx.xxx/xx. Members who would like to know more about their rights under the law, or think any services received while enrolled may not conform to the terms of the EOC, may contact the Washington State Office of Insurance Commissioner at toll-free 1-800-562-6900. Members who have a concern about the pharmacists or pharmacies serving them may call the Washington State Department of Health at toll-free 0-000-000-0000. Prescription Drug Coverage and Medicare: This benefit, for purposes of Creditable Coverage, is actuarially equal to or greater than the Medicare Part D prescription drug benefit. Members who are also eligible for Medicare Part D can remain covered and will not be subject to Medicare-imposed late enrollment penalties should they decide to enroll in a Medicare Part D plan at a later date; however, the Member could be subject to payment of higher Part D premiums if the Member subsequently has a break in creditable coverage of 63 continuous days or longer before enrolling in a Part D plan. A Member who discontinues coverage must meet eligibility requirements in order to re- enroll. Exclusions: Over-the-counter drugs, supplies and devices not requiring a prescription under state law or regulations, including most prescription vitamins, except as recommended by the U.S. Preventive Services Task Force (USPSTF); drugs and injections for anticipated illness while traveling; drugs and injections for cosmetic purposes; replacement of lost, stolen, or damaged drugs or devices; administration of excluded drugs and injectables; drugs used in the treatment of sexual dysfunction disorders; compounds which include a non-FDA approved drug; growth hormones for idiopathic short stature without growth hormone deficiency; prescription drugs/products available over-the-counter or have an over-the-counter alternative that is determined to be therapeutically interchangeable Emergency Services Emergency services at a Network Facility or non-Network Facility. See Section XII. for a definition of Emergency. Emergency services include professional services, treatment and supplies, facility costs, outpatient charges for patient observation and medical screening exams required to stabilize a patient. Members must notify KFHPWA by way of the Hospital notification line within 24 hours of any admission, or as soon thereafter as medically possible. If a Member is admitted as an inpatient directly from an emergency department, any Emergency services Copayment is waived. Coverage is subject to the hospital services Cost Share. If a Member is hospitalized in a non-Network Facility, KFHPWA reserves the right to require transfer of the Member to a Network Facility upon consultation between a Network Provider and the attending physician. If the Member refuses to transfer to a Network Facility or does not notify KFHPWA within 24 hours following admission, all further costs incurred during the hospitalization are the responsibility of the Member. Follow-up care which is a direct result of the Emergency must be received from a Network Provider, unless Preauthorization is obtained for such follow-up care from a non-Network Provider. Network Facility: After Deductible, Member pays 20% Plan Coinsurance Non-Network Facility: After Deductible, Member pays 20% Plan Coinsurance Hearing Examinations and Hearing Aids Hearing exams for hearing loss and evaluation are covered only when provided at KFHPWA-approved facilities. Cochlear implants or Bone Anchored Hearing Aids (BAHA) when in accordance with KFHPWA clinical criteria. Covered services for cochlear implants and BAHA include diagnostic testing, pre-implant testing, implant surgery, post- implant follow-up, speech therapy, programming and associated supplies (such as transmitter cable, and batteries). Hospital - Inpatient: After Deductible, Member pays 20% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 20% Plan Coinsurance Outpatient Services: After Deductible, Member pays 20% Plan Coinsurance Hearing aids including hearing aid examinations. Not covered; Member pays 100% of all charges Exclusions: Programs or treatments for hearing loss or hearing care including, but not limited to, externally worn hearing or surgically implanted hearing aids and the surgery and services necessary to implant them except as described above; hearing screening tests required under Preventive Services Home Health Careless

Appears in 1 contract

Samples: Group Medical Coverage Agreement

Outpatient Services. After Deductible, Member pays 20% Plan Coinsurance Injections administered by a Network Provider in a clinical setting during dialysis. Outpatient Services: After Deductible, Member pays 20% Plan Coinsurance Self-administered injectables. See Drugs – Outpatient Prescription for additional pharmacy information. Certain Preventive medications as determined by KFHPWA: Not subject to Deductible. Member pays 20% coinsurance Preferred generic drugs (Tier 1): After Deductible, Member pays ~~$15 Copayment~~ 20% coinsurance per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): After Deductible, Member pays ~~$30 Copayment~~ 20% coinsurance per 30- days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): ~~Not covered;~~ After Deductible, Member pays ~~100~~20% ~~of all charges~~ coinsurance per 30-days up to a 90-day supply Drugs - Outpatient Prescription Prescription drugs, supplies and devices for a supply of 30 days or less including diabetic pharmacy supplies (insulin, lancets, lancet devices, needles, insulin syringes, insulin pens, pen needles and blood glucose test strips), mental health and wellness drugs, self-administered injectables, medications for the treatment arising from sexual assault, and routine costs for prescription medications provided in a clinical trial. “Routine costs” means items and services delivered to the Member that are consistent with and typically covered by the plan or coverage for a Member who is not enrolled in a clinical trial. All drugs, supplies and devices must be for Covered Services. All drugs, supplies and devices must be obtained at a KFHPWA-designated pharmacy except for drugs dispensed for Emergency services or for Emergency services obtained outside of the KFHPWA Service Area including out of the country. Information regarding KFHPWA-designated Certain Preventive medications as determined by KFHPWA: Not subject to Deductible. Member pays 20% coinsurance Preferred generic drugs (Tier 1): After Deductible, Member pays 20% coinsurance per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): After Deductible, Member pays 20% coinsurance per 30- days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): After Deductible, Member pays 20% coinsurance per 30-days up to a 90-day supply pharmacies is reflected in the KFHPWA Provider Directory or can be obtained by contacting Xxxxxx Permanente Member Services. Prescription drug Cost Shares are payable at the time of delivery. Certain brand name insulin drugs are covered at the generic drug Cost Share. Preferred generic drugs (Tier 1): After Deductible, Member pays $15 Copayment per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): After Deductible, Member pays $30 Copayment per 30- days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): Not covered; Member pays 100% of all charges Annual Deductible does not apply to glucose monitors, test strips, lancets or control solutions. Note: A Member will not pay more than $100, not subject to the Deductible, for a 30-day supply of insulin to comply with state law requirements. Any cost sharing paid will apply toward the annual Deductible. Members may be eligible to receive an emergency fill for certain prescription drugs filled outside of KFHPWA’s business hours or when KFHPWA cannot reach the prescriber for consultation. For emergency fills, Members pay the prescription drug Cost Share for each 7-day supply or less, or the minimum packaging size available at the time the emergency fill is dispensed. A list of prescription drugs eligible for emergency fills is available on the pharmacy website at xxx.xx.xxx/xx/xxxxxxxxx. Members can request an emergency fill by calling 0-000-000-0000. Certain drugs are subject to Preauthorization as shown in the Preferred drug list (formulary) available at xxx.xx.xxx/xx/xxxxxxxxx. Annual Deductible does not apply to glucose monitors, test strips, lancets or control solutions. Note: A Member will not pay more than $100, not subject to the Deductible, for a 30-day supply of insulin to comply with state law requirements. Any cost sharing paid will apply toward the annual Deductible. Injections administered by a Network Provider in a clinical setting. After Deductible, Member pays 20% Plan Coinsurance Over-the-counter drugs not included under Preventive Care or Reproductive Health. Not covered; Member pays 100% of all charges Mail order drugs dispensed through the KFHPWA-designated mail order service. Member pays the prescription drug Cost Share for each 30 90 day supply or less Annual Deductible does not apply to glucose monitors, test strips, lancets or control solutions. Note: A Member will not pay more than $100, not subject to the Deductible, for a 30-day supply of insulin to comply with state law requirements. Any cost sharing paid will apply toward the annual Deductible. The KFHPWA Preferred drug list is a list of prescription drugs, supplies, and devices considered to have acceptable efficacy, safety and cost-effectiveness. The Preferred drug list is maintained by a committee consisting of a group of physicians, pharmacists and a consumer representative who review the scientific evidence of these products and determine the Preferred and Non-Preferred status as well as utilization management requirements. Preferred drugs generally have better scientific evidence for safety and effectiveness and are more affordable than Non-Preferred drugs. The preferred drug list is available at xxx.xx.xxx/xx/xxxxxxxxx, or upon request from Member Services. Members may request a coverage determination by contacting Member Services. Coverage determination reviews may include requests to cover non-preferred drugs, obtain Preauthorization for a specific drug, or exceptions to other utilization management requirements, such as quantity limits. If coverage of a non-Preferred drug is approved, the drug will be covered at the Preferred drug level. Prescription drugs are drugs which have been approved by the Food and Drug Administration (FDA) and which can, under federal or state law, be dispensed only pursuant to a prescription order. These drugs, including off-label use of FDA-approved drugs (provided that such use is documented to be effective in one of the standard reference compendia; a majority of well-designed clinical trials published in peer-reviewed medical literature document improved efficacy or safety of the agent over standard therapies, or over placebo if no standard therapies exist; or by the federal secretary of Health and Human Services) are covered. “Standard reference compendia” means the American Hospital Formulary Service – Drug Information; the American Medical Association Drug Evaluation; the United States Pharmacopoeia – Drug Information, or other authoritative compendia as identified from time to time by the federal secretary of Health and Human Services. “Peer-reviewed medical literature” means scientific studies printed in health care journals or other publications in which original manuscripts are published only after having been critically reviewed for scientific accuracy, validity and reliability by unbiased independent experts. Peer-reviewed medical literature does not include in-house publications of pharmaceutical manufacturing companies. Generic drugs are dispensed whenever available. A generic drug is a drug that is the pharmaceutical equivalent to one or more brand name drugs. Such generic drugs have been approved by the Food and Drug Administration as meeting the same standards of safety, purity, strength and effectiveness as the brand name drug. Brand name drugs are dispensed if there is not a generic equivalent. In the event the Member elects to purchase a brand-name drug instead of the generic equivalent (if available), the Member is responsible for paying the difference in cost in addition to the prescription drug Cost Share which does not apply to the Out-of-pocket Limit. Drug coverage is subject to utilization management that includes Preauthorization, step therapy (when a Member tries a certain medication before receiving coverage for a similar, but non-Preferred medication), limits on drug quantity or days supply and prevention of overutilization, underutilization, therapeutic duplication, drug-drug interactions, incorrect drug dosage, drug-allergy contraindications and clinical abuse/misuse of drugs. If a Member has a new prescription for a chronic condition, the Member may request a coordination of medications so that medications for chronic conditions are refilled on the same schedule (synchronized). Cost-shares for the initial fill of the medication will be adjusted if the fill is less than the standard quantity. Please contact Member Services for more information. Specialty drugs are high-cost drugs prescribed by a physician that requires close supervision and monitoring for serious and/or complex conditions, such as rheumatoid arthritis, hepatitis or multiple sclerosis. Specialty drugs must be obtained through KFHPWA’s preferred specialty pharmacy vendor and/or network of specialty pharmacies and are covered at the appropriate cost share above. For a list of specialty drugs or more information about KFHPWA’s specialty pharmacy network, please go to the KFHPWA website at xxx.xx.xxx/xx/xxxxxxxxx or contact Member Services at 206-630-4636 or toll-free at 1-888-901-4636. The Member’s Right to Safe and Effective Pharmacy Services: State and federal laws establish standards to assure safe and effective pharmacy services, and to guarantee Members’ right to know what drugs are covered and the coverage limitations. Members who would like more information about the drug coverage policies, or have a question or concern about their pharmacy benefit, may contact KFHPWA at 000-000-0000 or toll-free 1-888-901-4636 or by accessing the KFHPWA website at xxx.xx.xxx/xx. Members who would like to know more about their rights under the law, or think any services received while enrolled may not conform to the terms of the EOC, may contact the Washington State Office of Insurance Commissioner at toll-free 1-800-562-6900. Members who have a concern about the pharmacists or pharmacies serving them may call the Washington State Department of Health at toll-free 0-000-000-0000. Prescription Drug Coverage and Medicare: This benefit, for purposes of Creditable Coverage, is actuarially equal to or greater than the Medicare Part D prescription drug benefit. Members who are also eligible for Medicare Part D can remain covered and will not be subject to Medicare-imposed late enrollment penalties should they decide to enroll in a Medicare Part D plan at a later date; however, the Member could be subject to payment of higher Part D premiums if the Member subsequently has a break in creditable coverage of 63 continuous days or longer before enrolling in a Part D plan. A Member who discontinues coverage must meet eligibility requirements in order to re- enroll. Exclusions: Over-the-counter drugs, supplies and devices not requiring a prescription under state law or regulations, including most prescription vitamins, except as recommended by the U.S. Preventive Services Task Force (USPSTF); drugs and injections for anticipated illness while traveling; drugs and injections for cosmetic purposes; replacement of lost, stolen, or damaged drugs or devices; administration of excluded drugs and injectables; drugs used in the treatment of sexual dysfunction disorders; compounds which include a non-FDA approved drug; growth hormones for idiopathic short stature without growth hormone deficiency; prescription drugs/products available over-the-counter or have an over-the-counter alternative that is determined to be therapeutically interchangeable Emergency Services Emergency services at a Network Facility or non-Network Facility. See Section XII. for a definition of Emergency. Emergency services include professional services, treatment and supplies, facility costs, outpatient charges for patient observation and medical screening exams required to stabilize a patient. Members must notify KFHPWA by way of the Hospital notification line within 24 hours of any admission, or as soon thereafter as medically possible. If a Member is admitted as an inpatient directly from an emergency department, any Emergency services Copayment is waived. Coverage is subject to the hospital services Cost Share. If a Member is hospitalized in a non-Network Facility, KFHPWA reserves the right to require transfer of the Member to a Network Facility upon consultation between a Network Provider and the attending physician. If the Member refuses to transfer to a Network Facility or does not notify KFHPWA within 24 hours following admission, all further costs incurred during the hospitalization are the responsibility of the Member. Follow-up care which is a direct result of the Emergency must be received from a Network Provider, unless Preauthorization is obtained for such follow-up care from a non-Network Provider. Network Facility: After Deductible, Member pays 20% Plan Coinsurance Non-Network Facility: After Deductible, Member pays 20% Plan Coinsurance Hearing Examinations and Hearing Aids Hearing exams for hearing loss and evaluation are covered only when provided at KFHPWA-approved facilities. Cochlear implants or Bone Anchored Hearing Aids (BAHA) when in accordance with KFHPWA clinical criteria. Covered services for cochlear implants and BAHA include diagnostic testing, pre-implant testing, implant surgery, post- implant follow-up, speech therapy, programming and associated supplies (such as transmitter cable, and batteries). Hospital - Inpatient: After Deductible, Member pays 20% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 20% Plan Coinsurance Outpatient Services: After Deductible, Member pays 20% Plan Coinsurance Hearing aids including hearing aid examinations. Not covered; Member pays 100% of all charges Exclusions: Programs or treatments for hearing loss or hearing care including, but not limited to, externally worn hearing or surgically implanted hearing aids and the surgery and services necessary to implant them except as described above; hearing screening tests required under Preventive Services Home Health Careother

Appears in 1 contract

Samples: Group Medical Coverage Agreement

Outpatient Services. After Deductible, Member pays 20% Plan Coinsurance Injections administered by a Network Provider in a clinical setting during dialysis. Outpatient Services: After Deductible, Member pays 20% Plan Coinsurance Self-administered injectables. See Drugs – Outpatient Prescription for additional pharmacy information. Preferred generic drugs (Tier 1): After Deductible, Member pays $15 Copayment per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): After Deductible, Member pays $30 Copayment per 30- days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): Not covered; Member pays 100% of all charges Drugs - Outpatient Prescription Prescription drugs, supplies and devices for a supply of 30 days or less including diabetic pharmacy supplies (insulin, lancets, lancet devices, needles, insulin syringes, disposable insulin pens, pen needles and blood glucose test strips), mental health and wellness drugs, self-administered injectables, medications for the treatment arising from sexual assault, and routine costs for prescription medications provided in a clinical trial. “Routine costs” means items and services delivered to the Member that are consistent with and typically covered by the plan or coverage for a Member who is not enrolled in a clinical trial. All drugs, supplies and devices must be for Covered Services. All drugs, supplies and devices must be obtained at a KFHPWA-designated pharmacy except for drugs dispensed for Emergency services or for Emergency services obtained outside of the KFHPWA Service ~~Area~~ Area, including out of the country. Information regarding KFHPWA-designated pharmacies is reflected in the KFHPWA Provider Directory or can be obtained by contacting Xxxxxx Permanente Member Services. Prescription drug Cost Shares are payable at the time of delivery. Certain brand name insulin drugs are covered at the generic drug Cost Share. Preferred generic drugs (Tier 1): After Deductible, Member pays $15 Copayment per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): After Deductible, Member pays $30 Copayment per 30- days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): Not covered; Member pays 100% of all charges Annual Deductible does not apply to glucose monitors, test strips, lancets or control solutions. Note: A Member will not pay more than $100, not subject to the Deductible, for a 30-day supply of insulin to comply with state law requirements. Any cost sharing paid will apply toward the annual Deductible. Members may be eligible to receive an emergency fill for certain prescription drugs filled outside of KFHPWA’s business hours or when KFHPWA cannot reach the prescriber for consultation. For emergency fills, Members pay the prescription drug Cost Share for each 7-day supply or less, or the minimum packaging size available at the time the emergency fill is dispensed. A list of prescription drugs eligible for emergency fills is available on the pharmacy website at xxx.xx.xxx/xx/xxxxxxxxx. Members can request an emergency fill by calling 0-000-000-0000. Preferred generic drugs (Tier 1): After Deductible, Member pays $15 Copayment per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): After Deductible, Member pays $30 Copayment per 30- days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): Not covered; Member pays 100% of all charges Annual Deductible does not apply to strip-based blood glucose monitors, test strips, lancets or control solutions. Note: A Member will not pay more than $35, not subject to the Deductible, for a 30-day supply of insulin to comply with state law requirements. Any cost sharing paid will apply toward the annual Deductible. Certain drugs are subject to Preauthorization as shown in the Preferred drug list (formulary) available at xxx.xx.xxx/xx/xxxxxxxxx. For outpatient prescription drugs and/or items that are covered under the Drugs – Outpatient Prescription section and obtained at a pharmacy owned and operated by KFHPWA, a Member may be able to use approved manufacturer coupons as payment for the Cost Sharing that a Member owes, as allowed under KFHPWA’s coupon program. A Member will owe any additional amount if the coupon does not cover the entire amount of the Cost Sharing for the Member’s prescription. When a Member uses an approved coupon for payment of their Cost Sharing, the coupon amount and any additional payment that you make will accumulate to their Out-of-Pocket Limit, however; the amount will not apply toward the Deductible. More information is available regarding the Xxxxxx Permanente coupon program rules and limitations at xx.xxx/xxxxxxxxx. Injections administered by a Network Provider in a clinical setting. After Deductible, Member pays 20% Plan Coinsurance Over-the-counter drugs not included under Preventive Care or Reproductive Health. Not covered; Member pays 100% of all charges Mail order drugs dispensed through the KFHPWA-designated mail order service. Member pays the prescription drug Cost Share for each 30 day supply or less Annual Deductible does not apply to strip-based blood glucose monitors, test strips, lancets or control solutions. Note: A Member will not pay more than $~~100~~35, not subject to the Deductible, for a 30-day supply of insulin to comply with state law requirements. Any cost sharing paid will apply toward the annual Deductible. The KFHPWA Preferred drug list is a list of prescription drugs, supplies, and devices considered to have acceptable efficacy, safety and cost-effectiveness. The Preferred drug list is maintained by a committee consisting of a group of physicians, pharmacists and a consumer representative who review the scientific evidence of these products and determine the Preferred and Non-Preferred status as well as utilization management requirements. Preferred drugs generally have better scientific evidence for safety and effectiveness and are more affordable than Non-Preferred drugs. The preferred drug list is available at xxx.xx.xxx/xx/xxxxxxxxx, or upon request from Member Services. Members may request a coverage determination by contacting Member Services. Coverage determination reviews may include requests to cover non-preferred drugs, obtain Preauthorization for a specific drug, or exceptions to other utilization management requirements, such as quantity limits. If coverage of a non-Preferred drug is approved, the drug will be covered at the Preferred drug level. Prescription drugs are drugs which have been approved by the Food and Drug Administration (FDA) and which can, under federal or state law, be dispensed only pursuant to a prescription order. These drugs, including off-label use of FDA-approved drugs (provided that such use is documented to be effective in one of the standard reference compendia; a majority of well-designed clinical trials published in peer-reviewed medical literature document improved efficacy or safety of the agent over standard therapies, or over placebo if no standard therapies exist; or by the federal secretary of Health and Human Services) are covered. “Standard reference compendia” means the American Hospital Formulary Service – Drug Information; the American Medical Association Drug Evaluation; the United States Pharmacopoeia – Drug Information, or other authoritative compendia as identified from time to time by the federal secretary of Health and Human Services. “Peer-reviewed medical literature” means scientific studies printed in health care journals or other publications in which original manuscripts are published only after having been critically reviewed for scientific accuracy, validity and reliability by unbiased independent experts. Peer-reviewed medical literature does not include in-house publications of pharmaceutical manufacturing companies. Generic drugs are dispensed whenever available. A generic drug is a drug that is the pharmaceutical equivalent to one or more brand name drugs. Such generic drugs have been approved by the Food and Drug Administration as meeting the same standards of safety, purity, strength and effectiveness as the brand name drug. Brand name drugs are dispensed if there is not a generic equivalent. In the event the Member elects to purchase a brand-name drug instead of the generic equivalent (if available), the Member is responsible for paying the difference in cost in addition to the prescription drug Cost Share which does not apply to the Out-of-pocket Limit. Drug coverage is subject to utilization management that includes Preauthorization, step therapy (when a Member tries a certain medication before receiving coverage for a similar, but non-Preferred medication), limits on drug quantity or days supply and prevention of overutilization, underutilization, therapeutic duplication, drug-drug interactions, incorrect drug dosage, drug-allergy contraindications and clinical abuse/misuse of drugs. If a Member has a new prescription for a chronic condition, the Member may request a coordination of medications so that medications for chronic conditions are refilled on the same schedule (synchronized). Cost-shares for the initial fill of the medication will be adjusted if the fill is less than the standard quantity. Please contact Member Services for more information. Specialty drugs are high-cost drugs prescribed by a physician that requires close supervision and monitoring for serious and/or complex conditions, such as rheumatoid arthritis, hepatitis or multiple sclerosis. Specialty drugs must be obtained through KFHPWA’s preferred specialty pharmacy vendor and/or network of specialty pharmacies and are covered at the appropriate cost share above. For a list of specialty drugs or more information about KFHPWA’s specialty pharmacy network, please go to the KFHPWA website at xxx.xx.xxx/xx/xxxxxxxxx or contact Member Services at ~~206~~000-~~630~~000-~~4636~~ 0000 or toll-free at 10-~~888~~000-~~901~~000-~~4636~~0000. The Member’s Right to Safe and Effective Pharmacy Services: State and federal laws establish standards to assure safe and effective pharmacy services, and to guarantee Members’ right to know what drugs are covered and the coverage limitations. Members who would like more information about the drug coverage policies, or have a question or concern about their pharmacy benefit, may contact KFHPWA at 000-000-0000 or toll-free 10-~~888~~000-~~901~~000-~~4636~~ 0000 or by accessing the KFHPWA website at xxx.xx.xxx/xx. Members who would like to know more about their rights under the law, or think any services received while enrolled may not conform to the terms of the EOC, may contact the Washington State Office of Insurance Commissioner at toll-free 10-~~800~~000-~~562~~000-~~6900~~0000. Members who have a concern about the pharmacists or pharmacies serving them may call the Washington State Department of Health at toll-free 0-000-000-0000. Prescription Drug Coverage and Medicare: This benefit, for purposes of Creditable Coverage, is actuarially equal to or greater than the Medicare Part D prescription drug benefit. Members who are also eligible for Medicare Part D can remain covered and will not be subject to Medicare-imposed late enrollment penalties should they decide to enroll in a Medicare Part D plan at a later date; however, the Member could be subject to payment of higher Part D premiums if the Member subsequently has a break in creditable coverage of 63 continuous days or longer before enrolling in a Part D plan. A Member who discontinues coverage must meet eligibility requirements in order to re- enroll. Exclusions: Over-the-counter drugs, supplies and devices not requiring a prescription under state law or regulations, including most prescription vitamins, except as recommended by the U.S. Preventive Services Task Force (USPSTF); drugs and injections for anticipated illness while traveling; drugs and injections for cosmetic purposes; replacement of lost, stolen, or damaged drugs or devices; administration of excluded drugs and injectables; drugs used in the treatment of sexual dysfunction disorders; compounds which include a non-FDA approved drug; growth hormones for idiopathic short stature without growth hormone deficiency; prescription drugs/products available over-the-counter or have an over-the-counter alternative that is determined to be therapeutically interchangeable Emergency Services Emergency services at a Network Facility or non-Network Facility. See Section XII. for a definition of Emergency. Emergency services include professional services, treatment and supplies, facility costs, outpatient charges for patient ~~observation and~~ observation, medical screening exams required to stabilize a ~~patient~~patient and post stabilization. Members must notify KFHPWA by way of the Hospital notification line within 24 hours of any admission, or as soon thereafter as medically possible. If a Member is admitted as an inpatient or to Advanced Care at Home directly from an emergency department, any Emergency services Copayment is waived. Coverage is subject to the hospital services Cost Share. If a Member is hospitalized in a non-Network Facility, KFHPWA reserves the right to require transfer of the Member to a Network Facility upon consultation between a Network Provider and the attending physician. If the Member refuses to transfer to a Network Facility or does not notify KFHPWA within 24 hours following admission, all further costs incurred during the hospitalization are the responsibility of the Member. Follow-up care which is a direct result of the Emergency must be received from a Network Provider, unless Preauthorization is obtained for such follow-up care from a non-Network Provider. Network Facility: After Deductible, Member pays 20% Plan Coinsurance Non-Network Facility: After Deductible, Member pays 20% Plan Coinsurance Gender Services Medically Necessary medical and surgical services for gender affirmation. Consultation and treatment requires Preauthorization. Prescription drugs are covered the same as for any other condition (see Drugs - Outpatient Prescription for coverage). Counseling services are covered the same as for any other condition (see Mental Health and Wellness for coverage). Hospital - Inpatient: After Deductible, Member pays 20% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 20% Plan Coinsurance Outpatient Services: After Deductible, Member pays 20% Plan Coinsurance Non-Emergency inpatient hospital services require Preauthorization. Exclusions: Cosmetic services and surgery not related to gender affirming treatment (i.e., face lift or calf implants), complications of non-Covered Services Hearing Examinations and Hearing Aids Hearing exams for hearing loss and evaluation are covered only when provided at KFHPWA-approved facilities. Cochlear implants or Bone Anchored Hearing ~~Aids~~ System (~~BAHA~~BAHS) when in accordance with KFHPWA clinical criteria. Covered services for initial cochlear implants and ~~BAHA~~ BAHS include diagnostic testing, pre-implant testing, implant surgery, ~~post-~~ post-implant follow-up, speech therapy, programming and associated supplies (such as transmitter cable, and batteries). Replacement devices and associated supplies – see Devices, Equipment and Supplies Section. Hospital - Inpatient: After Deductible, Member pays 20% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 20% Plan Coinsurance Outpatient Services: After Deductible, Member pays 20% Plan Coinsurance Hearing aids including hearing aid examinations. Not covered; Member pays 100% of all charges Exclusions: Programs or treatments for hearing loss or hearing care including, but not limited to, externally worn hearing or surgically implanted hearing aids and the surgery and services necessary to implant them except as described above; hearing screening tests required under Preventive Services Home Health ~~Care~~Care Home health care when the following criteria are met: • Except for patients receiving palliative care services, the Member must be unable to leave home due to their health problem or illness. Unwillingness to travel and/or arrange for transportation does not constitute inability to leave the home. • The Member requires intermittent skilled home health care, as described below. • KFHPWA’s medical director determines that such services are Medically Necessary and are most appropriately rendered in the Member’s home. Covered Services for home health care may include the following when rendered pursuant to a KFHPWA-approved home health care plan of treatment: nursing care; restorative physical, occupational, respiratory and speech therapy; durable medical equipment; medical social worker and limited home health aide services. Home health services are covered on an intermittent basis in After Deductible, Member pays 20% Plan Coinsurance

Appears in 1 contract

Samples: Group Medical Coverage Agreement

Common use of Outpatient Services Clause in Contracts