Coverage for Contraception Where a Prescription Is Not Required. Your plan covers contraception with no Cost Sharing even when a Prescription is not required. Contraceptive methods such as condoms or Plan B may fall into this category. You will not have to pay upfront for contraceptives that do not require a Prescription when obtained through an In- network Pharmacy. For all other purchases, you may submit a request for reimbursement as follows: Within 90 days of the date of purchase of the contraceptive method Provide the receipt with the item name and amount, your name, address, plan ID number, to the following: Address: Presbyterian Insurance Company, Inc. Pharmacy Department P.O. Box 26267 Albuquerque, NM 87125-6267 Email: xxxxxxxxxxx@xxx.xxx Fax: (000) 000-0000 If you submit your complete request for reimbursement electronically or by fax, we will reimburse you within 30 days of receiving the request. If you submit your complete request for reimbursement by U.S. mail, we will reimburse within 45 days. Please ensure all information on the reimbursement request is complete to prevent any delays.
Coverage for Contraception Where a Prescription Is Not Required. Your plan covers contraception with no cost sharing even when a prescription is not required. Contraceptive methods such as condoms or Plan B may fall into this category. You will not have to pay upfront for contraceptives that do not require a prescription when obtained through an in-network pharmacy. For all other purchases, you may submit a request for reimbursement as follows: • Within 90 days of the date of purchase of the contraceptive method, • [Provide the receipt with the item name and amount, your name, address, plan ID number, to the following: Address: Presbyterian Health Plan X.X. Xxx 00000 Xxxxxxxxxxx, XX 00000-0000 Email: If you submit your complete request for reimbursement electronically or by fax, we will reimburse you within 30 days of receiving the request. If you submit your complete request for reimbursement by U.S. mail, we will reimburse within 45 days. Failure to submit a complete request may lead to delays in reimbursement. Availability of Out-of-Network Coverage Under your plan, use of an out-of-network provider to prescribe or dispense contraceptive coverage is not a covered benefit.] This endorsement is retroactive to the effective date of your coverage with us. These terms replace and supersede any conflicting provision of your insurance contract and summary of benefits and coverage. All other requirements of the policy not in conflict with this endorsement still apply. Table of Contents Endorsement 1 3 PRIOR AUTHORIZATION 3 Endorsement 2 6 OUT-OF-NETWORK CARE AND BILLS 6 If you pay an out-of-network provider more than we determine you owe: 7 Endorsement 3 8 NO COST SHARING FOR BEHAVIORAL HEALTH SERVICES 8 Endorsement 4 9 CONTRACEPTIVE COVERAGE SUMMARY ENDORSEMENT 9 Welcome 22 Welcome to Presbyterian Health Plan! 22 Our Agreement with You 22 Understanding This Agreement 23 Customer Assistance 24 Member Rights and Responsibilities 26 This Section explains your rights and responsibilities under this Agreement and how you can participate on our Consumer Advisory Board. Member Rights 26 Additional Member Rights and Responsibilities 27 Consumer Advisory Board 29 How the Plan Works 30 This section explains how to find Practitioners/Providers who are in our Network (In- network), get Healthcare Services both In-network and Out-of-network, requirements you must follow when getting care and how to receive Covered Benefits under this Agreement. Provider Directory 31 Obtaining Healthcare 31 How to Obtain Primary Care Services 31 Women’s ...
Coverage for Contraception Where a Prescription Is Not Required. Your plan covers contraception with no Cost Sharing even when a prescription is not required. Contraceptive methods such as condoms or Plan B may fall into this category. You will not have to pay upfront for contraceptives that do not require a prescription when obtained through an In- network pharmacy. For all other purchases, you may submit a request for reimbursement as follows:• Within 90 days of the date of purchase of the contraceptive method,• Provide the receipt with the item name and amount, your name, address, plan ID number, to the following: Address: Presbyterian Health Plan
Coverage for Contraception Where a Prescription Is Not Required. Your plan covers contraception with no cost sharing even when a prescription is not required. Contraceptive methods such as condoms or Plan B may fall into this category. You will not have to pay upfront for contraceptives that do not require a prescription when obtained through an in-network pharmacy. For all other purchases, you may submit a request for reimbursement as follows: • Within 90 days of the date of purchase of the contraceptive method, • [Provide the receipt with the item name and amount, your name, address, plan ID number, to the following: Address: Presbyterian Health Plan X.X. Xxx 00000 Xxxxxxxxxxx, XX 00000-0000 Email: If you submit your complete request for reimbursement electronically or by fax, we will reimburse you within 30 days of receiving the request. If you submit your complete request for reimbursement by U.S. mail, we will reimburse within 45 days. Failure to submit a complete request may lead to delays in reimbursement.
Coverage for Contraception Where a Prescription Is Not Required. Your plan covers contraception with no Cost Sharing even when a prescription is not required. Contraceptive methods such as condoms or Plan B may fall into this category. You will not have to pay upfront for contraceptives that do not require a prescription when obtained through an In- network pharmacy. For all other purchases, you may submit a request for reimbursement as follows: • Within 90 days of the date of purchase of the contraceptive method • Provide the receipt with the item name and amount, your name, address, plan ID number, to the following: Address: Presbyterian Health Plan Attn.: Pharmacy Dept. P.O. Box 27489 Albuquerque, NM 87125-7489 Email: xxx.xxxxxxxxxxx@xxx.xxx Fax: (000) 000-0000 If you submit your complete request for reimbursement electronically or by fax, we will reimburse you within 30 days of receiving the request. If you submit your complete request for reimbursement by U.S. mail, we will reimburse within 45 days. Please ensure all information on the reimbursement request is complete to prevent delays in reimbursement. Availability of Out-of-Network Coverage Under your plan, use of an Out-of-network Provider to prescribe or dispense contraceptive coverage is a Covered benefit. Please refer to the Prescription drug coverage section Summary of Benefits and Coverage to learn more about your out-of-network benefit.
