Exclusions, Prior Authorizations and Quantity Limits Sample Clauses

Exclusions, Prior Authorizations and Quantity Limits. In addition to the above referenced “member pays the difference” also known as “generic incentive,” the prescription plan has certain drugs which are excluded because they are either covered under the medical plan or used for cosmetic purposes, etc.; some drugs have set quantity limits and/or require prior authorization which is established by the PBM. Increases in quantity limit amounts must be authorized by the employee’s physician and the PBM.
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