Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+): For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Tier 5: $125 Not Covered When purchased at a Retail Pharmacy (+): For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Specialty Prescription Drugs purchasedat a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservice. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% Not Covered Tier 2: 20% Not Covered Tier 3: 20% Not Covered Tier 4: 20% Not Covered When purchased at a Specialty Pharmacy (+) Tier 5: 20% Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% Not Covered Contraceptive Methods- Preventive Coverage includes barrier method (diaphragmor cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered
Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy(+): Copayment applies per each 30-day supply or applies per recommended treatment interval. Tier 4: $150 Not Covered Tier 5: $300 Not Covered When purchased at a Retail Pharmacy(+): Copayment applies per each 30-day supply or applies per recommended treatment interval. Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 4: 50% Not Covered Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Infertility Prescription Drugs - Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% Not Covered Tier 2: 20% Not Covered Tier 3: 20% Not Covered When purchased at a Specialty Pharmacy(+) Tier 4: 20% Not Covered Tier 5: 20% Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy
Specialty Prescription Drugs (+ selected Prescription Drugs which are typically used to treat rare or complex conditions and which may require special handling, monitoring and/or special or limited distribution systems, including dispensing through an Exclusive Pharmacy Provider.
Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy(+): Copayment applies per each 30-day supply or applies per recommended treatment interval. Tier 4: $65 Tier 4: 50% Our reimbursement is based on the pharmacy allowance. You are responsible to pay up to the retail cost of the drug. When purchased at a Retail Pharmacy(+): Copayment applies per each 30-day supply or applies per recommended treatment interval. Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Tier 4: 50% Our reimbursement is based on the pharmacy allowance. You are responsible to pay up to the retail cost of the drug. Tier 4: 50% Our reimbursement is based on the pharmacy allowance. You are responsible to pay up to the retail cost of the drug. When purchased at a Mail Order Pharmacy: Not Covered Not Covered Infertility Prescription Drugs (+) - Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% Not Covered Tier 2: 20% Not Covered Tier 3: 20% Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy
Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy(+): Copayment applies per each 30-day supply or applies per recommended treatment interval. Tier 5: $125 - After deductible Not Covered When purchased at a Retail Pharmacy(+): Copayment applies per each 30-day supply or applies per recommended treatment interval. Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% - After deductible Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Infertility Prescription Drugs - Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% - After deductible Not Covered Tier 2: 20% - After deductible Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy
Specialty Prescription Drugs (+ selected Prescription Drugs which are typically used to treat rare or complex conditions and which may require special handling, monitoring and/or special or limited distribution systems, including dispensing through an Exclusive Pharmacy Provider. 137. STANDARD VALUE - the level of Network benefits providing for Member cost-sharing which is higher than the Enhanced Value level of benefits. 138. STATE-OWNED PSYCHIATRIC HOSPITAL - a Facility Provider, that is owned and operated by the Commonwealth of Pennsylvania, which has been approved by Medicare, The Joint Commission or the American Osteopathic Hospital Association and which, for compensation from its patients, is primarily engaged in providing treatment and/or care for the Inpatient treatment of Mental Illness for individuals aged eighteen (18) and older whose hospitalization is ordered by a court of competent jurisdiction through a civil commitment proceeding. 139. SUBSCRIBER - an applicant who has satisfied the specifications of SECTION SE - SCHEDULE OF ELIGIBILITY of this Agreement, signed the Application, and with whom the Plan has entered into this Agreement.
Specialty Prescription Drugs (+ selected Prescription Drugs which are typically used to treat rare or complex conditions and which may require special handling, monitoring and/or special or limited distribution systems, including dispensing through an Exclusive Pharmacy Provider. 137. STANDARD VALUE - the level of Network benefits providing for Member cost- sharing which is higher than the Preferred Value level of benefits and the Enhanced Value level of benefits.
Specialty Prescription Drugs (+. When purchased at a Specialty Pharmacy(+) Copayment applies per each 30-day supply or applies per recommended treatment interval. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Medication Synchronization above for details. Tier 5: $0 - After deductible Not Covered When purchased at a Retail Pharmacy(+) Applicable for each 30-day supply or recommended treatment interval. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Medication Synchronization above for details. Specialty Prescription Drugs purchased at a Retail Pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: $0 - After deductible Not Covered When purchased at a Mail Order Pharmacy(+) Tier 5: Not Covered Not Covered
Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+): Copayment applies per each 30-day supply or applies per recommended treatment interval. Tier 4: $65 Tier 4: 50% Our reimbursement is based on the pharmacy allowance. When purchased at a Retail Pharmacy (+): Copayment applies per each 30-day supply or applies per recommended treatment interval. Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Tier 4: 50% Our reimbursement is based on the pharmacy allowance. Tier 4: 50% Our reimbursement is based on the pharmacy allowance. When purchased at a Mail Order Pharmacy: Not Covered Not Covered Infertility Prescription Drugs - Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% Not Covered Tier 2: 20% Not Covered Tier 3: 20% Not Covered When purchased at a Specialty Pharmacy(+) Tier 4: 20% Tier 4: 20% Our reimbursement is based on the pharmacy allowance.
Specialty Prescription Drugs (+. The parties hereby agree to participate in the ProAct Specialty Prescription Drug Program. Effective January 1, 2023 the copay for covered specialty drugs will increase to 30% but only for prescription drugs eligible for manufacturer copay assistance. Any member participating in the City of Plattsburgh Employee Benefit Plan (“Member”) who purchases a covered specialty drug that qualifies for manufacturer copay assistance does not have any out of pocket cost for Copay under the City’s prescription drug plan. If manufacturer copay assistance is not available, members will be subject to the applicable prescription drug copay outlined in the Collective Bargaining Agreement between the Parties, and the terms of the City Health Insurance Plan elected by the member. The parties acknowledge that covered Specialty Prescription Drugs subject to this MOA must be filled by the Noble Health Exclusive Network based on the requirements of the City’s Health Plans.
