Benefits Program – Details and Methods of Coverage Sample Clauses

Benefits Program – Details and Methods of Coverage. The benefits summarized in the Group Benefits Program shall be procured by the Company under contracts with insurance companies or health care contractors and/or administrative agents, which will be in the form customarily written by such companies or contractor or administrative agents and the Group Benefits Program shall be subject to the terms and conditions of such contracts and/or administrative agents to develop various programs designed to contain costs, based on those portions of the Group Benefits Program and which contain the requirement that charges are covered only on the basis of medical necessity. Such cost containment programs or procedures may be utilized to determine the medical necessity of the treatment itself, the appropriateness of the services provided, the place of treatment, or the duration of treatment. These programs may include incentives for employees and dependents to use services of an approved Preferred Provider Organization. The carriers or administrative agents and Company will announce each such program or procedure before it is required or available to the affected employees. Any such cost containment program will not operate to reduce the benefits of such Group Benefits Program or any covered person or to shift the costs covered under such Group Benefits Program to the covered person. The failure of an insurance company or health care contractor or administrative agent to provide for any of the services or benefits for which it has contracted shall result in no liability to the Company, nor shall such failure be considered a breach by the Company of the obligations which it has undertaken by this Agreement. However, in the event of any such failure, the Company shall immediately attempt to provide substitute coverage.
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Related to Benefits Program – Details and Methods of Coverage

  • State Employee Group Insurance Program (SEGIP) During the life of this Agreement, the Employer agrees to offer a Group Insurance Program that includes health, dental, life, and disability coverages equivalent to existing coverages, subject to the provisions of this Article. All insurance eligible employees will be provided with a Summary Plan Description (SPD) called “Your Employee Benefits”. Such SPD shall be provided no less than biennially and prior to the beginning of the insurance year. New insurance eligible employees shall receive a SPD within thirty (30) days of their date of eligibility.

  • Procurement Plan 8. The Borrower shall update the Procurement Plan as needed throughout implementation of the Project, and on each anniversary of the Effective Date, the Borrower shall in consultation with ADB determine whether the Procurement Plan needs to be updated. The Borrower shall implement the Procurement Plan in the manner in which it has been approved by ADB.

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  • Pharmacy Benefits - Prescription Drugs and Diabetic Equipment or Supplies from a Pharmacy This plan covers prescription drugs listed on our formulary and diabetic equipment or supplies bought from a pharmacy as a pharmacy benefit. These benefits are administered by our Pharmacy Benefit Manager (PBM). Our formulary includes a tiered copayment structure and indicates that certain prescription drugs require preauthorization. If a prescription drug is not on our formulary, it is not covered. For specific coverage information or a copy of the most current formulary, please visit our website or call our Customer Service Department. Prescription drugs and diabetic equipment or supplies are covered when dispensed using the following guidelines: • the prescription must be medically necessary, consistent with the physician’s diagnosis, ordered by a physician whose license allows him or her to order it, filled at a pharmacy whose license allows such a prescription to be filled, and filled according to state and federal laws; • the prescription must consist of legend drugs that require a physician’s prescription under law, or compound medications made up of at least one legend drug requiring a physician’s prescription under law; • the prescription must be dispensed at the proper place of service as determined by our Pharmacy and Therapeutics Committee. For example, certain prescription drugs may only be covered when obtained from a specialty pharmacy; and • the prescription is limited to the quantities authorized by your physician not to exceed the quantity listed in the Summary of Pharmacy Benefits. Prescription drugs are subject to the benefit limits and the amount you pay shown in the Summary of Pharmacy Benefits.

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  • Medical Benefits - Prescription Drugs Administered by a Provider (other than a pharmacist) This plan covers prescription drugs as a medical benefit, referred to as “medical prescription drugs”, when the prescription drug requires administration (or the FDA approved recommendation is administration) by a licensed healthcare provider (other than a pharmacist). Please note: Specialty prescription drugs meeting these requirements or recommendations are covered as a pharmacy benefit and not a medical benefit. These medical prescription drugs include, but are not limited to, medications administered by infusion, injection, or inhalation, as well as nasal, topical or transdermal administered medications. For some of these medical prescription drugs, the cost of the prescription drug is included in the allowance for the medical service being provided, and is not separately reimbursed.

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