Retail Pharmacy. The maximum supply of a drug for which benefits will be provided when dispensed under any one prescription is a 30 day supply. Diabetic equipment, drugs and supplies Specialty Pharmacy The maximum supply of a Specialty Drug for which benefits will be provided when dispensed under any one prescription is a 30 day supply. Mail Order Prescription Drug Program The maximum supply of a drug for which benefits will be provided when dispensed under any one prescription is a 1-90-day supply. Diabetic drugs and supplies Deductible & then: Tier 1 $10 Copay per Covered Drug Tier 2 $25 Copay per Covered Drug Tier 3 $40 Copay per Covered Drug Tier 1 $10 Copay per Covered Drug Tier 2 $25 Copay per Covered Drug Tier 3 $40 Copay per Covered Drug Tier 1 $10 Copay per Covered Drug Tier 2 $50 Copay per Covered Drug Tier 3 $80 Copay per Covered Drug Deductible & Coinsurance per prescription Deductible & Coinsurance per prescription Deductible & Coinsurance per prescription Human Organ and Tissue Transplant Services Unlimited maximum Deductible Deductible & Coinsurance Home Health Care (Including In-Home Hospice Care) Nursing and therapeutic services limited to 200 visits In the Home Hospice Medical Social Services under the direction of a Physician Up to $420. Deductible Deductible Deductible & Coinsurance Deductible & Coinsurance Infusion Therapy Unlimited lifetime maximum Deductible Deductible & Coinsurance Durable Medical Equipment and Prosthetic Devices Hearing Aid Coverage Available for dependent children age 12 years and under Diabetic equipment, and supplies Deductible Deductible & 50% Coinsurance Ostomy Related Services Deductible Deductible & 50% Coinsurance Hospice Care (inpatient) Deductible Deductible & Coinsurance Wig Up to $500 maximum per Member per Calendar Year. Deductible Deductible & Coinsurance Specialized Formula Deductible Deductible & Coinsurance Infertility Services Please see Maternity/Family Planning Section of this document Office Visit Outpatient Hospital Inpatient Hospital Infertility Drugs The maximum supply of a drug for which benefits will be provided when dispensed under any one prescription is 30 day supply Deductible Same as Hospital Outpatient Cost-Share Same as Hospital Inpatient Cost-Share Deductible Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Maternity Deductible Deductible & Coinsurance Note: Out of Network services applicable after Deductible and Coinsurance. Covered Person is resp...
Retail Pharmacy. All payments made to providers relating specifically to retail pharmacy services. However, if payment is made to a provider on the basis of total cost of care, such payment should be included even retail pharmacy spending is included in total cost of care for the calculation of such payments. • Other non-clinical: Payments made pursuant to the payer’s contract with a provider that were not made on the basis of medical services and that cannot be properly classified in the included categories below. Examples include infrastructure incentive payments, EMR/HIT adoption incentive payments, governmental payer shortfall payments, grants, or other surplus payments. • Other Federal: Payments made on behalf of members enrolled in the Federal Employees’ Health Benefit Program, TRICARE, or other military programs. Payments made for Medicare Advantage members should be included.
Retail Pharmacy. The term "Retail Pharmacy" shall mean a pharmacy at whose location patients appear in person to submit prescriptions, or at whose location prescriptions are picked up or received by patients who are present in person.
Retail Pharmacy. Generic Drugs: $17 co-pay after deductible (up to 30 Day) Preferred Brand: 30% co-pay after deductible Non-preferred Brand: 50% co-pay after deductible Mail Order: Generic Drugs: $34 co-pay after deductible Pharmacy Preferred Brand: 30% co-pay x 2 of retail cost after deductible (up to 90 Day) Non-preferred Brand: 50% co-pay x 2 retail cost after deductible Out of Network prescriptions: Pay 40% after deductible • CareFirst Premier Plan PPO - In Network Annual Deductible: $400 deductible per person, $800 deductible per family Out of Pocket Max: $2200 per person, $4400 per family Coinsurance: 20% af ter deductible Office Visit: $20 co-pay Specialty Visit: $40 co-pay Imaging/Labs: 20% af ter deducible Emer. Room: 20% af ter deducible plus $150 copay (waived if admitted) Outpatient: 20% af ter deducible Inpatient: 20% af ter deducible Non-PPO – Out of Network Annual Deductible: $800 deductible per person, $1600 deductible per family Out of Pocket Max: $4400 per person, $8800 per family Coinsurance: 40% af ter deductible Office Visit: 40% af ter deductible Specialty Visit: 40% af ter deductible Imaging/Labs: 40% af ter deducible Emer. Room: 20% af ter in network deducible plus $150 copay (waived if admitted) Outpatient: 40% af ter deducible Inpatient: 40% af ter deducible The Out of Pocket Maximum does include the Annual Deductible Co-pays apply to out of pocket only Prescription Drugs Retail Pharmacy: Generic Drugs: $10 co-pay (up to 30 Day) Preferred Brand: $30 co-pay Non-preferred Brand: $60 co-pay Mail Order: Generic Drugs: $20 co-pay Pharmacy Preferred Brand: $60 co-pay (up to 90 Day) Non-preferred Brand: $120 co-pay Out of Network prescriptions: Pay 40% after deductible Employee contributions will be twenty percent (20%) of the total cost of the Saver Plan and thirty (30%) of the total cost of the Premier Plan, but will not exceed the annual 15% ceilings specif ied below: BiWeekly Employee Contribution CURRENT CEILING CEILING CEILING CEILING SAVER PLAN 1-Jan 21 1-Jan-22 1-Jan-23 1-Jan-24 1-Jan-25 Employee $48.24 15% Max 15% Max 15% Max 15% Max Employee + Child(ren) $88.23 increase increase increase increase Employee + Spouse $109.14 from from from from Family $145.52 previous year previous year previous year previous year BiWeekly Employee Contribution CURRENT CEILING CEILING CEILING CEILING PREMIER PLAN 1-Mar-18 1-Jan-22 1-Jan-23 1-Jan-24 1-Jan-25 Employee $105.41 15% Max 15% Max 15% Max 15% Max Employee + Child(ren) $179.13 increase increase increase in...
