Common use of Coverage for Contraception Where a Prescription Is Not Required Clause in Contracts

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 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 prescription when obtained through an In- network Pharmacypharmacy. For all other purchases, you may submit a request for reimbursement as follows: follows:• Within 90 days of the date of purchase of the contraceptive method method,• Provide the receipt with the item name and amount, your name, address, plan ID number, to the following: Address: Presbyterian Insurance Company, Inc. Health Plan‌‌‌ Attn.: Pharmacy Department Dept. P.O. Box 26267 27489 Albuquerque, NM 87125-6267 7489 Email: xxxxxxxxxxx@xxx.xxx 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 any delaysdelays in reimbursement.

Coverage for Contraception Where a Prescription Is Not Required. Your plan covers contraception with no Cost Sharing even when a Prescription 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 prescription when obtained through an In- network Pharmacypharmacy. 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 CompanyHealth Plan Attn.: Pharmacy Dept. X.X. Xxx 00000 Xxxxxxxxxxx, Inc. Pharmacy Department P.O. Box 26267 Albuquerque, NM 87125XX 00000-6267 0000 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. days Please ensure all information on the reimbursement request is complete to prevent any delaysdelays in reimbursement.

Coverage for Contraception Where a Prescription Is Not Required. Your plan covers contraception with no Cost Sharing cost sharing even when a Prescription 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 prescription when obtained through an In- in- network Pharmacypharmacy. 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 method, • Provide the receipt with the item name and amount, your name, address, plan ID number, to the following: Address: Presbyterian Insurance CompanyHealth Plan Attn.: Pharmacy Dept. X.X. Xxx 00000 Xxxxxxxxxxx, Inc. Pharmacy Department P.O. Box 26267 Albuquerque, NM 87125XX 00000-6267 0000 Email: xxxxxxxxxxx@xxx.xxx Fax: (xxx.xxxxxxxxxxx@xxx.xxx 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 delaysdelays in reimbursement.

Coverage for Contraception Where a Prescription Is Not Required. Your plan covers contraception with no Cost Sharing cost sharing even when a Prescription 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 prescription when obtained through an In- in- network Pharmacypharmacy. 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. Health Plan Attn.: Pharmacy Department Dept. P.O. Box 26267 27489 Albuquerque, NM 8712500000-6267 0000 Email: xxxxxxxxxxx@xxx.xxx Fax: (xxxxxxxxxxx@xxx.xxx 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 delaysdelays in reimbursement.

Coverage for Contraception Where a Prescription Is Not Required. Your plan covers contraception with no Cost Sharing even when a Prescription 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 prescription when obtained through an In- network Pharmacypharmacy. 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. Health Plan Attn.: Pharmacy Department Dept. P.O. Box 26267 27489 Albuquerque, NM 87125-6267 7489 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.delays in reimbursement.‌‌‌

Coverage for Contraception Where a Prescription Is Not Required. Your plan covers contraception with no Cost Sharing even when a Prescription 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 prescription when obtained through an In- network Pharmacypharmacy. 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. Health Plan Attn.: Pharmacy Department Dept. P.O. Box 26267 27489 Albuquerque, NM 87125-6267 7489 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.delays in reimbursement.‌‌‌