Common use of Subscriber Agreement Clause in Contracts

Subscriber Agreement. This section describes coverage for prescription drugs and diabetic equipment/supplies purchased at a retail, specialty, or mail order pharmacy. This section is a part of the Subscriber Agreement and not separate from it. Coverage is provided per the terms, conditions, exclusions, and limitations of this Subscriber Agreement. Required Preauthorization Prescription drugs for which preauthorization is required are marked with the symbol (+) in the Summary of Pharmacy Benefits. Preauthorization is required for certain brand name prescription drugs and certain specialty Prescription Drugs. For details on how to obtain prescription drug preauthorization for a prescription drug, see Section 1.6 and Section 3.28 - subsection “How to Obtain Prescription Drug Preauthorization. This prescription drug plan formulary has a four-tiered copayment structure. The copayment for a prescription drug will vary by tier. For more information about our formulary, and to see the tier placement of a particular prescription drug, visit our website or call our Customer Service Department. The Summary of Pharmacy Benefits table, below, indicates the tier structure and the amount that you are responsible to pay. The tier placement of our formulary is subject to change. Formulary Listing Our formulary lists generic, preferred brand name, and non-preferred brand name prescription drugs and specialty prescription drugs covered under this agreement. To obtain a copy of the most current formulary listing, visit our Web site at XXXXXX.xxx. or you may call our Customer Service Department at (000) 000-0000 or 0-000-000-0000 or Voice TDD 711. Medication Synchronization (less than a 30 day supply) In accordance with Rhode Island General Law §27-18-50.1, a prorated copayment may be applied for covered prescription drugs, used to treat chronic long-term conditions, when prescribed for less than a (30) thirty day supply and dispensed by a network pharmacy if: • the prescribing physician and pharmacist determine it is in the best interest of the member; and • the member requests or agrees to less than a thirty (30) day supply. In addition, in order to qualify for medication synchronization, the covered prescription drug must: • be a maintenance drug used for the management and treatment of a chronic long- term care condition; • not be a controlled substance; • meet all utilization management requirements specific to the drug; • be of a formulation able to be split over the required shortened supply period; and • not have quantity limits or dose optimization criteria that would be violated when synchronized with other prescription drugs.

Subscriber Agreement. This section describes coverage for prescription drugs and diabetic equipment/supplies purchased at a retail, specialty, or mail order pharmacy. This section is a part of the Subscriber Agreement and not separate from it. Coverage is provided per the terms, conditions, exclusions, and limitations of this Subscriber Agreement. Required Preauthorization Prescription drugs for which preauthorization is required are marked with the symbol (+) in the Summary of Pharmacy Benefits. Preauthorization is required for certain brand name prescription drugs and certain specialty Prescription Drugs. For details on how to obtain prescription drug preauthorization for a prescription drug, see Section 1.6 and Section 3.28 - subsection “How to Obtain Prescription Drug Preauthorization. This prescription drug plan formulary has a four-tiered copayment structure. The copayment for a prescription drug will vary by tier. For more information about our formulary, and to see the tier placement of a particular prescription drug, visit our website or call our Customer Service Department. The Summary of Pharmacy Benefits table, below, indicates the tier structure and the amount that you are responsible to pay. The tier placement of our formulary is subject to change. Formulary Listing Our formulary lists generic, preferred brand name, and non-preferred brand name prescription drugs and specialty prescription drugs covered under this agreement. To obtain a copy of the most current formulary listing, visit our Web site at XXXXXX.xxx. or you may call our Customer Service Department at (000) 000-0000 or 0-000-000-0000 or Voice TDD 711. Medication Synchronization (less than a 30 day supply) In accordance with Rhode Island General Law §27-18-50.1, a prorated copayment may be applied for covered prescription drugs, used to treat chronic long-term conditions, when prescribed for less than a (30) thirty day supply and dispensed by a network pharmacy if: •  the prescribing physician and pharmacist determine it is in the best interest of the member; and •  the member requests or agrees to less than a thirty (30) day supply. In addition, in order to qualify for medication synchronization, the covered prescription drug must: •  be a maintenance drug used for the management and treatment of a chronic long- term care condition; •  not be a controlled substance; •  meet all utilization management requirements specific to the drug; •  be of a formulation able to be split over the required shortened supply period; and •  not have quantity limits or dose optimization criteria that would be violated when synchronized with other prescription drugs.