SUMMARY OF PHARMACY BENEFITS Sample Clauses

SUMMARY OF PHARMACY BENEFITS. The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty, pharmacy. For information about our pharmacy network, visit our website or call our Customer Service Department.
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SUMMARY OF PHARMACY BENEFITS. Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for this service. Please see Preauthorization in Section 3 for more information. You Pay You Pay Prescription Drugs, other than Specialty Prescription Drugs, and Diabetic Equipment and Suppliesw( hich includes Glucometers, Test Strips, Lancet and Lancet Devices, Needles and Syringes, and Miscellaneous Suppl calibration fluid): When purchased at a Retail or Spaelctiy Pharmacy: Copaymentapplies per each 3-0day supply or portion thereof for maintenance and n-omnaintenance prescription drugs. For tiers 1, 2, and 3: Up to a -9d0ay supply of maintenance and no-nmaintenance prescription drugs is available at certain retail pharmacies. For -ad9ay0 supply; three retail copayments apply. For more information about pharmacies offering this optisoitn, our website. Proratedcopaymentsfor a shorter supply period may apply fornetwork pharmacoynly. See Prescription Drug section for details. Tier 1: $10 Not Covered Tier 2: $35 Not Covered Tier 3: $70 Not Covered Tier4 and Tier5: See specialty prescription drug section below. Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply of maintenance and n-on maintenance prescription drugs. Tier 1: $25 Not Covered Tier 2: $87.50 Not Covered Tier 3: $210 Not Covered Tier4 and Tier5: See specialty prescription drug section below. Not Covered Specialty Prescription Drugs (+)Prorated copayments for a shorter supply period may apply nfoetrwork pharmacy only. See Prescrpition Drug section for details. When purchased at a Specialty Pharmacy(+): Copaymentapplies per each 3-0day supply or applies per recommended treatment interval. Tier4: $150 Not Covered Tier5: $300 Not Covered When purchased at a Retail Pharmacy(+): Copaymentapplies per each 3-0day supply or applies per recommended treatment intervSapl.ecialty Prescription Drugpsurchased at a ertailpharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier4: 50% Not Covered Tier5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Infertility Prescription Drugs- Three (3) i-nvitro cycles will be covered perplan yearwith a total of eight (8)-viintro cycles covered in a P H liPfetimE e. H U ¶ V When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% NotCovered Tier 2: 20% Not Covered Tier 3:20% Not Covered When purchased at a ...
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SUMMARY OF PHARMACY BENEFITS. Covered Benefits Network Pharmacy Non-network Pharmacy
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SUMMARY OF PHARMACY BENEFITS. Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for this service. Please see Preauthorization in Section 3 for more information. You Pay You Pay Prescription Drugs, other than Specialty Prescription Drugs, and Diabetic Equipment and Supplies (which includes Glucometers, Test Strips, Lancet and Lancet Devices, Needles and Syringes, and Miscellaneous Supplies, calibration fluid): When purchased at a Retail or Specialty Pharmacy: Copayment applies per each 30-day supply or portion thereof for maintenance and non-maintenance prescription drugs. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. Tier 1: $7 Not Covered Tier 2: $35 Not Covered Tier 3: $50 - After deductible Not Covered Tier 4: $75 - After deductible Not Covered Tier 5: See specialty prescription drug section below. Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply of maintenance and non- maintenance prescription drugs. Tier 1: $17.50 Not Covered Tier 2: $87.50 Not Covered Tier 3: $125 - After deductible Not Covered Tier 4: $225 - After deductible Not Covered Tier 5: See specialty prescription drug section below. Not Covered
Sample 1
SUMMARY OF PHARMACY BENEFITS. Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Ambulance Services Ground $50 The level of coverage is the same as network provider. Air/water* $50 The level of coverage is the same as network provider.
Sample 1

Related to SUMMARY OF PHARMACY BENEFITS

  • Summary of Benefits Plan Feature Employee Co-pay - Network Only Preventive and Diagnostic Services • Examination • Cleaning • x-rays $0 $0 $0 Minor Restorative • Fillings and extractions • Oral surgery • Endodontic services1 • Periodontal services1 $0 $40-$196 based on specific service $45-$310 based on specific service $25-$145 based on specific service 1 Additional employee co-pay if approved specialist performs services. Major Restorative • Crowns • Bridges • Complete Dentures $92-$190 based on specific service $115-$291 based on specific service $249-$264 based on specific service Complete Orthodontics $1,850 co-pay D PPO “Buy Up” Option (Voluntary) Summary of Benefits Plan Feature In Network/Out of Network Class I (Preventative) 100%/100% Class II (Basic/Restorative) 80%/80% Class III (Major) 60%/60% Class IV (Orthodontia - adult ortho is included) 50%/50% Annual Deductible per Member (does not apply to Class I services) $50/$50 Orthodontia Lifetime Max $1,500/$1,500

  • Program Benefits Under the Probation Status, the Participating Contractor will be eligible for all contractor incentives, its customers will have access to financing offered through the Program, and income- eligible households will be eligible to receive Program incentives.

  • Covered Benefits and Services The Contractor shall provide to its Hoosier Healthwise members, at a minimum, all benefits and services deemed “medically reasonable and necessary” and covered by the IHCP, and included in the Indiana Administrative Code and under the Contract with the State. A covered service is considered medically necessary if it meets the definition as set forth in 405 IAC 5-2-17. The Contractor shall deliver covered services sufficient in amount, duration or scope to reasonably expect that provision of such services would achieve the purpose of the furnished services. Costs for these services are the basis of the Contractor’s capitation rate and are, therefore, the responsibility of the Contractor. Coverage may not be arbitrarily denied or reduced and is subject to certain limitations in accordance with CFR 438.210(a)(4), which specifies when Contractors may place appropriate limits on services:  On the basis of criteria applied under the State plan, such as medical necessity; or  For the purpose of utilization control, provided the services furnished are sufficient in amount, duration or scope to reasonably be expected to achieve the purpose for which the services are furnished.

  • Medical Benefits The Company shall reimburse the Employee for the cost of the Employee's group health, vision and dental plan coverage in effect until the end of the Termination Period. The Employee may use this payment, as well as any other payment made under this Section 6, for such continuation coverage or for any other purpose. To the extent the Employee pays the cost of such coverage, and the cost of such coverage is not deductible as a medical expense by the Employee, the Company shall "gross-up" the amount of such reimbursement for all taxes payable by the Employee on the amount of such reimbursement and the amount of such gross-up.

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  • Retiree Health Benefits 1. There is currently in effect a retiree health benefit program for retired members of LACERS under LAAC Division 4, Chapter 11. All covered employees who are members of LACERS, regardless of retirement tier, shall contribute to LACERS four percent (4%) of their pre-tax compensation earnable toward vested retiree health benefits as provided by this program. The retiree health benefit available under this program is a vested benefit for all covered employees who make this contribution, including employees enrolled in LACERS Tier 3.

  • Public Benefits This Agreement provides assurances that the Public Benefits identified below will be achieved and developed in accordance with the Applicable Rules and Project Approvals and with the terms of this Agreement and subject to the City’s Reserved Powers. The Project will provide Public Benefits to the City, including without limitation:

  • Community Benefits 31.1. The potential to take in to account social considerations (also referred to as Community Benefits) in public procurement is firmly established and set out in European Directive 2014/24/EU, the Public Contracts (Scotland) Regulations 2015 (“the Regulations”) and European case law.

  • Health Benefits The method for determining the Employer bi-weekly contributions to the cost of employee health insurance programs under the Federal Employees Health Benefits Program (FEHBP) will be as follows:

  • Retiree Medical Benefits If Executive is or would become fifty-five (55) or older and Executive's age and service equal sixty-five (65) and Executive has at least five (5) years of service with the Company within two (2) years of Change in Control, Executive is eligible for retiree medical benefits (as such are determined immediately prior to Change in Control). Executive is eligible to commence receiving such retiree medical benefits based on the terms and conditions of the applicable plans in effect immediately prior to the Change in Control.

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