Common use of Member Reimbursement Clause in Contracts

Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; however, if you go to an Out-of-network (outside of the 5-county area) Pharmacy, and they are unable to process the claim at point of service you can pay for the prescription and submit a Member Reimbursement Form. Reimbursement will be based on the negotiated rate between Presbyterian Health Plan and the dispensing pharmacy minus any copay or coinsurance that may apply. The form together with the itemized cash register receipt and the prescription drug detail (pharmacy pamphlet) must contain the following information: • Patient’s name • Patient’s Date of Birth • Name of the drug • Quantity dispensed • NDC (National Drug Code) • Fill Date • Name of Prescriber • Name and phone number of the dispensing pharmacy • Reason for the purchase (nature of emergency) • Proof of Payment Member Reimbursement forms are available by calling our Presbyterian Customer Service Center, Monday through Friday, from 7 a.m. to 6 p.m. at (000) 000-0000 or 0-000-000-0000. Hearing impaired users may call TTY 711. A Pharmacy Services Call Center is available 24 hours a day to providers and pharmacies to address pharmacy benefit questions and prior authorization requests. Please contact the Provider Line at 0-000-000-0000. A registered professional nurse or physician shall be immediately available by telephone 24 hours a day, seven days a week, to render utilization management determinations for providers. Presbyterian shall provide all members and providers with a toll-free telephone number by which to contact utilization management staff on at least a five-day, 40 hours a week basis. All members must have immediate telephone access 24 hours a day, seven days a week, to their Primary Care Physician or the physician’s authorized on-call back-up provider. When these providers are unavailable, a registered nurse or physician on the utilization management staff must be available to respond to inquiries concerning emergency or urgent care. In the event Medically Necessary Covered services are not reasonably available through participating healthcare professionals, Presbyterian shall allow the PCP or other participating healthcare professional to refer a member to a non-participating healthcare professional and shall fully reimburse the non-participating healthcare professional at the usual, customary, and reasonable rate or at an agreed-upon rate. Before Presbyterian may deny such a referral to a non- participating physician or healthcare professional, the request must be reviewed by a specialist similar to the type of specialist to whom a referral is requested.

Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; however, if you go to an Out-of-network (outside of the 5-county area) Pharmacy, and they are unable to process the claim at the point of service you can may pay for the prescription and submit a Member Reimbursement Formmay request Presbyterian Insurance Company to reimburse you. Reimbursement A Pharmacy Specialist will be review and process your request for reimbursement based on the negotiated rate between Presbyterian Health Plan Insurance Company and the dispensing pharmacy minus any copay or coinsurance that may apply. Members will not be liable to a provider for any sums owed to the provider by Presbyterian. The form together with Pharmacy Specialist needs the following information to determine reimbursement amounts. Please submit a Member Reimbursement Form and attach the itemized cash register receipt and the prescription drug detail (pharmacy pamphlet) must contain along with the following information: • Patient’s name • Patient’s Date of Birth • Name of the drug • Quantity dispensed • NDC (National Drug Code) • Fill Date • Name of Prescriber • Name and phone number of the dispensing pharmacy • Reason for the purchase (nature of emergency) • Proof of Payment payment Member Reimbursement forms are available by calling our Presbyterian Customer Service Center, Monday through Friday, from 7 a.m. to 6 p.m. Center at (000) 000-0000 or 0-000-000-0000. , Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. Please follow the mailing instructions on the Member Reimbursement Form. A Pharmacy Services Call Center is available 24 hours a day to providers providers, pharmacies and pharmacies members to address pharmacy benefit questions and prior authorization requestsquestions. Please contact the Provider Line PCSC at 0-000-000-0000. A registered professional nurse or physician shall be immediately available by telephone 24 hours a day, seven days a week, to render utilization management determinations for providers. providers.‌‌ Presbyterian shall provide all members and providers with a toll-free telephone number by which to contact utilization management staff on at least a five-day, 40 hours a week basis. All members must have immediate telephone access 24 hours a day, seven days a week, to their Primary Care Physician or the physician’s authorized on-call back-up provider. When these providers are unavailable, a registered nurse or physician on the utilization management staff must be available to respond to inquiries concerning emergency or urgent care. In the event Medically Necessary Covered services are not reasonably available through participating healthcare professionals, Presbyterian shall allow the PCP or other participating healthcare professional to refer a member to a non-participating healthcare professional and shall fully reimburse the non-participating healthcare professional at the usual, customary, and reasonable rate or at an agreed-upon rate. Before Presbyterian may deny such a referral to a non- participating physician or healthcare professional, the request must be reviewed by a specialist similar to the type of specialist to whom a referral is requested.

Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; however, if you go to an Out-of-network (outside of the 5-county area) Pharmacy, and they are unable to process the claim at point of service you can pay for the prescription and submit a Member Reimbursement Form. Reimbursement will be based on the negotiated rate between Presbyterian Health Plan and the dispensing pharmacy minus any copay or coinsurance that may apply. Members will not be liable to a Provider for any sums owed to the Provider by Presbyterian. The form together with the itemized cash register receipt and the prescription drug detail (pharmacy pamphlet) must contain the following information: • Patient’s name • Patient’s Date of Birth • Name of the drug • Quantity dispensed • NDC (National Drug Code) • Fill Date • Name of Prescriber • Name and phone number of the dispensing pharmacy • Reason for the purchase (nature of emergency) • Proof of Payment Member Reimbursement forms are available by calling our Presbyterian Customer Service Center, Monday through Friday, Friday from 7 a.m. to 6 p.m. at (000) 000-0000 or 0-000-000-0000. Hearing impaired users may call TTY 711. A The Presbyterian Health Plan Pharmacy Services Call Center Service Team is available 24 hours a day to providers and pharmacies to address pharmacy benefit questions and prior authorization Prior Authorization requests. Please contact the Provider Line at (000) 000-0000 or 0-000-000-00000000 and follow the voice prompts and select Pharmacy. A registered professional nurse or physician shall be immediately available by telephone phone 24 hours a day, seven days a week, week to render utilization management determinations for providers. Presbyterian shall provide all members and providers with a toll-free telephone number by which to contact utilization management staff on at least a five-day, 40 hours a week basis. All members must have immediate telephone phone access 24 hours a day, seven days a week, week to their Primary Care Physician PCP or the physicianprovider’s authorized on-call back-up provider. When these providers are unavailable, a registered nurse or physician on the utilization management staff must be available to respond to inquiries concerning emergency or urgent careUrgent Care. In the event Medically Necessary Covered services are not reasonably available through participating healthcare professionals, Presbyterian shall allow the PCP or other participating healthcare professional to refer a member Member to a non-participating healthcare professional and shall fully reimburse the non-participating healthcare professional at the usual, customary, and reasonable rate or at an agreed-upon rate. Before Presbyterian may deny such a referral to a non- participating physician or healthcare professional, the request must be reviewed by a specialist similar to the type of specialist to whom a referral is requested.

Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; however, if you go to an Out-of-network (outside of the 5-county area) Pharmacy, and they are unable to process the claim at point of service you can may pay for the prescription and submit a Member Reimbursement Formmay request Presbyterian Health Plan to reimburse you. Reimbursement A Pharmacy Specialist will be review and process your request for reimbursement based on the negotiated rate between Presbyterian Health Plan and the dispensing pharmacy minus any copay or coinsurance that may apply. Members will not be liable to a provider for any sums owed to the provider by Presbyterian. The form together with Pharmacy Specialist needs the following information to determine reimbursement amounts. Please submit a Member Reimbursement Form and attach the itemized cash register receipt and the prescription drug detail (pharmacy pamphlet) must contain along with the following information: • Patient’s name Patient Name • Patient’s Date of Birth • Name of the drug • Quantity dispensed • NDC (National Drug Code) Code • Fill Date • Name of Prescriber • Name and phone number of the dispensing pharmacy • Reason for the purchase (nature of emergency) • Proof of Payment Member Reimbursement forms are available by calling our Presbyterian Customer Service Center, Monday through Friday, from 7 a.m. to 6 p.m. Center at (000) 000-0000 or 0-000-000-0000. , Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call our TTY line at 711. Please follow the mailing instructions on the Member Reimbursement Form. A Pharmacy Services Call Center is available 24 hours a day to providers providers, pharmacies and pharmacies members to address pharmacy benefit questions and prior authorization requestsquestions. Please contact the Provider Line PCSC at 0-000-000-0000. A registered professional nurse or physician shall be immediately available by telephone 24 hours a day, seven days a week, to render utilization management determinations for providers. Presbyterian shall provide all members and providers with a toll-free telephone number by which to contact utilization management staff on at least a five-day, 40 hours a week basis. All members must have immediate telephone access 24 hours a day, seven days a week, to their Primary Care Physician or the physician’s authorized on-call back-up provider. When these providers are unavailable, a registered nurse or physician on the utilization management staff must be available to respond to inquiries concerning emergency or urgent care. In the event Medically Necessary Covered services are not reasonably available through participating healthcare professionals, Presbyterian shall allow the PCP or other participating healthcare professional to refer a member to a non-participating healthcare professional and shall fully reimburse the non-participating healthcare professional at the usual, customary, and reasonable rate or at an agreed-upon rate. Before Presbyterian may deny such a referral to a non- participating physician or healthcare professional, the request must be reviewed by a specialist similar to the type of specialist to whom a referral is requested.seven

Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; however, if you go to an Out-of-network (outside of the 5-county area) Network Pharmacy, and they are unable to process the claim at point of service you can may pay for the prescription and submit a Member Reimbursement Formmay request Presbyterian Health Plan to reimburse you. Reimbursement A Pharmacy Specialist will be review and process your request for reimbursement based on the negotiated rate between Presbyterian Health Plan and the dispensing pharmacy minus any copay Copay or coinsurance Coinsurance that may apply. Members will not be liable to a provider for any sums owed to the provider by Presbyterian. The form together with Pharmacy Specialist needs the following information to determine reimbursement amounts. Please submit a Member Reimbursement Form and attach the itemized cash register receipt and the prescription drug detail (pharmacy pamphlet) must contain along with the following information: • Patient’s name Name • Patient’s Date of Birth • Name of the drug • Quantity dispensed • NDC (National Drug Code) • Fill Date • Name of Prescriber • Name and phone number of the dispensing pharmacy • Reason for the purchase (nature of emergency) • Proof of Payment Member Reimbursement forms are available by calling our Presbyterian Customer Service Center, Monday through Friday, from 7 a.m. to 6 p.m. at (000) 000-0000 or 0-000-000-0000. 0000 Hearing impaired users may call TTY 711. A Please follow the mailing instructions on the Member Reimbursement Form. The Presbyterian Health Plan Pharmacy Services Call Center Service Team is available 24 hours a day to providers providers, pharmacies and pharmacies members to address pharmacy benefit questions and prior authorization requestsquestions. Please contact the Provider Line them at (000) 000-0000 or 0-000-000-00000000 (select option 6 when calling either number). A registered professional nurse or physician shall be immediately available by telephone seven days a week, 24 hours a day, seven days a week, to render utilization management determinations for providers. Presbyterian shall provide all members and providers with a toll-free telephone number by which to contact utilization management staff on at least a five-day, 40 hours a week basis. All members must have immediate telephone access seven days a week, 24 hours a day, seven days a week, to their Primary Care Physician PCP or the physician’s authorized on-call back-up provider. When these providers are unavailable, a registered nurse or physician on the utilization management staff must be available to respond to inquiries concerning emergency or urgent care. In the event Medically Necessary Covered covered services are not reasonably available through participating healthcare professionals, Presbyterian shall allow the PCP or other participating healthcare professional to refer a member to a non-participating healthcare professional and shall fully reimburse the non-participating healthcare professional at the usual, customary, and reasonable rate or at an agreed-agreed upon rate. Before Presbyterian may deny such a referral to a non- participating physician or healthcare professional, the request must be reviewed by a specialist similar to the type of specialist to whom a referral is requested.

Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; however, if you go to an Out-of-network (outside of the 5-county area) Pharmacy, and they are unable to process the claim at the point of service you can may pay for the prescription and submit a Member Reimbursement Formmay request Presbyterian Insurance Company to reimburse you. Reimbursement A Pharmacy Specialist will be review and process your request for reimbursement based on the negotiated rate between Presbyterian Health Plan Insurance Company and the dispensing pharmacy minus any copay or coinsurance that may apply. Members will not be liable to a provider for any sums owed to the provider by Presbyterian. The form together with Pharmacy Specialist needs the following information to determine reimbursement amounts. Please submit a Member Reimbursement Form and attach the itemized cash register receipt and the prescription drug detail (pharmacy pamphlet) must contain along with the following information: • Patient’s name • Patient’s Date of Birth • Name of the drug • Quantity dispensed • NDC (National Drug Code) • Fill Date • Name of Prescriber • Name and phone number of the dispensing pharmacy • Reason for the purchase (nature of emergency) • Proof of Payment payment Member Reimbursement forms are available by calling our Presbyterian Customer Service Center, Monday through Friday, from 7 a.m. to 6 p.m. Center at (000) 000-0000 or 0-000-000-0000. , Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. A Please follow the mailing instructions on the Member Reimbursement Form. The Presbyterian Health Plan Pharmacy Services Call Center Service Team is available 24 hours a day to providers providers, pharmacies and pharmacies members to address pharmacy benefit questions and prior authorization requestsquestions. Please contact the Provider Line them at (000) 000-0000 or 0-000-000-00000000 (select option 6 when calling either number). A registered professional nurse or physician shall be immediately available by telephone 24 hours a day, seven days a week, to render utilization management determinations for providers. Presbyterian shall provide all members and providers with a toll-free telephone number by which to contact utilization management staff on at least a five-day, 40 hours a week basis. All members must have immediate telephone access 24 hours a day, seven days a week, to their Primary Care Physician or the physician’s authorized on-call back-up provider. When these providers are unavailable, a registered nurse or physician on the utilization management staff must be available to respond to inquiries concerning emergency or urgent care. In the event Medically Necessary Covered services are not reasonably available through participating healthcare professionals, Presbyterian shall allow the PCP or other participating healthcare professional to refer a member to a non-participating healthcare professional and shall fully reimburse the non-participating healthcare professional at the usual, customary, and reasonable rate or at an agreed-upon rate. Before Presbyterian may deny such a referral to a non- participating physician or healthcare professional, the request must be reviewed by a specialist similar to the type of specialist to whom a referral is requested.

Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; however, if you go to an Out-of-network (outside of the 5-county area) Pharmacy, and they are unable to process the claim at point of service you can may pay for the prescription and submit a Member Reimbursement Formmay request Presbyterian Health Plan to reimburse you. Reimbursement A Pharmacy Specialist will be review and process your request for reimbursement based on the negotiated rate between Presbyterian Health Plan and the dispensing pharmacy minus any copay or coinsurance that may apply. Members will not be liable to a provider for any sums owed to the provider by Presbyterian. The form together with Pharmacy Specialist needs the following information to determine reimbursement amounts. Please submit a Member Reimbursement Form and attach the itemized cash register receipt and the prescription drug detail (pharmacy pamphlet) must contain along with the following information: • Patient’s name Patient Name • Patient’s Date of Birth • Name of the drug • Quantity dispensed • NDC (National Drug Code) Code • Fill Date • Name of Prescriber • Name and phone number of the dispensing pharmacy • Reason for the purchase (nature of emergency) • Proof of Payment Member Reimbursement forms are available by calling our Presbyterian Customer Service Center, Monday through Friday, from 7 a.m. to 6 p.m. Center at (000) 000-0000 or 0-000-000-0000. , Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. Please follow the mailing instructions on the Member Reimbursement Form. A Pharmacy Services Call Center is available 24 hours a day to providers providers, pharmacies and pharmacies members to address pharmacy benefit questions and prior authorization requestsquestions. Please contact the Provider Line PCSC at 0-000-000-0000. A registered professional nurse or physician shall be immediately available by telephone 24 hours a day, seven days a week, to render utilization management determinations for providers. Presbyterian shall provide all members and providers with a toll-free telephone number by which to contact utilization management staff on at least a five-day, 40 hours a week basis. All members must have immediate telephone access 24 hours a day, seven days a week, to their Primary Care Physician or the physician’s authorized on-call back-up provider. When these providers are unavailable, a registered nurse or physician on the utilization management staff must be available to respond to inquiries concerning emergency or urgent care. In the event Medically Necessary Covered services are not reasonably available through participating healthcare professionals, Presbyterian shall allow the PCP or other participating healthcare professional to refer a member to a non-participating healthcare professional and shall fully reimburse the non-participating healthcare professional at the usual, customary, and reasonable rate or at an agreed-upon rate. Before Presbyterian may deny such a referral to a non- participating physician or healthcare professional, the request must be reviewed by a specialist similar to the type of specialist to whom a referral is requested.seven

Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; , however, if you go to an Out-of-network (outside of the 5-county area) Pharmacy, and they are unable to process the claim at point of service you can may pay for the prescription and submit a Member Reimbursement Formmay request Presbyterian Health Plan to reimburse you. Reimbursement A Pharmacy Specialist will be review and process your request for reimbursement based on the negotiated rate between Presbyterian Health Plan and the dispensing pharmacy minus any copay or coinsurance that may apply. Members will not be liable to a provider for any sums owed to the provider by Presbyterian. The form together with Pharmacy Specialist needs the following information to determine reimbursement amounts. Please submit a Member Reimbursement Form and attach the itemized cash register receipt and the prescription drug detail (pharmacy pamphlet) must contain along with the following information: . • Patient’s name Name • Patient’s Date of Birth • Name of the drug Drug • Quantity dispensed • NDC (( National Drug Code) • Fill Date • Name of Prescriber • Name and phone number of the dispensing pharmacy • Reason for the purchase (nature of emergency) • Proof of Payment Member Reimbursement forms are available by calling our Presbyterian Customer Service Center, Monday through Friday, from 7 a.m. to 6 p.m. at (000) 000-0000 or 01-000855-000923-0000. Hearing 7528Hearing impaired users may call TTY 711. A The Presbyterian Health Plan Pharmacy Services Call Center Service Team is available 24 hours a day to providers providers, pharmacies and pharmacies members to address pharmacy benefit questions and prior authorization requestsquestions. Please contact the Provider Line them at (000) 000-0000 or 0-000-000-00000000 (select option 6 when calling either number). A registered professional nurse or physician shall be immediately available by telephone seven days a week, 24 hours a day, seven days a week, to render utilization management determinations for providers. Presbyterian shall provide all members and providers with a toll-free telephone number by which to contact utilization management staff on at least a five-day, 40 hours a week basis. All members must have immediate telephone access seven days a week, 24 hours a day, seven days a week, to their Primary Care Physician or the physician’s authorized on-call back-up provider. When these providers are unavailable, a registered nurse or physician on the utilization management staff must be available to respond to inquiries concerning emergency or urgent care. In the event Medically Necessary Covered services are not reasonably available through participating healthcare professionalsprofessional, Presbyterian shall allow the PCP or other participating healthcare professional to refer a member Member to a non-participating healthcare professional and shall fully reimburse the non-participating healthcare professional at the usual, customary, and reasonable rate or at an agreed-upon rate. Before Presbyterian may deny such a referral to a non- participating physician or healthcare professional, the request must be reviewed by a specialist similar to the type of specialist to whom a referral is requested.

Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; however, if you go to an Out-of-network (outside of the 5-county area) Pharmacy, and they are unable to process the claim at point of service you can pay for the prescription and submit a Member Reimbursement Form. Reimbursement will be based on the negotiated rate between Presbyterian Health Plan and the dispensing pharmacy minus any copay or coinsurance that may apply. Members will not be liable to a Provider for any sums owed to the Provider by Presbyterian. The form together with the itemized cash register receipt and the prescription drug detail (pharmacy pamphlet) must contain the following information: • · Patient’s name • · Patient’s Date of Birth • · Name of the drug • · Quantity dispensed • · NDC (National Drug Code) • · Fill Date • · Name of Prescriber • · Name and phone number of the dispensing pharmacy • · Reason for the purchase (nature of emergency) • · Proof of Payment Member Reimbursement forms are available by calling our Presbyterian Customer Service Center, Monday through Friday, from 7 a.m. to 6 p.m. at (000) 000-0000 or 0-000-000-0000. Hearing impaired users may call TTY 711. A The Presbyterian Health Plan Pharmacy Services Call Center Service Team is available 24 hours a day to providers and pharmacies to address pharmacy benefit questions and prior authorization Prior Authorization requests. Please contact the Provider Line at (000) 000-0000 or 0-000-000-00000000 and follow the prompts and select pharmacy. A registered professional nurse or physician shall be immediately available by telephone 24 hours a day, seven days a week, to render utilization management determinations for providers. Presbyterian shall provide all members and providers with a toll-free telephone number by which to contact utilization management staff on at least a five-day, 40 hours a week basis. All members must have immediate telephone access 24 hours a day, seven days a week, to their Primary Care Physician or the physician’s authorized on-call back-up provider. When these providers are unavailable, a registered nurse or physician on the utilization management staff must be available to respond to inquiries concerning emergency or urgent care. In the event Medically Necessary Covered services are not reasonably available through participating healthcare professionals, Presbyterian shall allow the PCP or other participating healthcare professional to refer a member to a non-participating healthcare professional and shall fully reimburse the non-participating healthcare professional at the usual, customary, and reasonable rate or at an agreed-upon rate. Before Presbyterian may deny such a referral to a non- participating physician or healthcare professional, the request must be reviewed by a specialist similar to the type of specialist to whom a referral is requested.

Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; however, if you go to an Out-of-network (outside of the 5-county area) Pharmacy, and they are unable to process the claim at the point of service you can may pay for the prescription and submit a Member Reimbursement Formmay request Presbyterian Health Plan to reimburse you. Reimbursement A Pharmacy Specialist will be review and process your request for reimbursement based on the negotiated rate between Presbyterian Health Plan and the dispensing pharmacy minus any copay or coinsurance that may apply. Members will not be liable to a provider for any sums owed to the provider by Presbyterian. The form together with Pharmacy Specialist needs the following information to determine reimbursement amounts. Please submit a Member Reimbursement Form and attach the itemized cash register receipt and the prescription drug detail (pharmacy pamphlet) must contain along with the following information: • Patient’s name • Patient’s Date of Birth • Name of the drug • Quantity dispensed • NDC (National Drug Code) • Fill Date • Name of Prescriber • Name and phone number of the dispensing pharmacy • Reason for the purchase (nature of emergency) • Proof of Payment payment Member Reimbursement forms are available by calling our Presbyterian Customer Service Center, Monday through Friday, from 7 a.m. to 6 p.m. Center at (000) 000-0000 or 0-000-000-0000. , Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call our TTY line at 711. Please follow the mailing instructions on the Member Reimbursement Form. A Pharmacy Services Call Center is available 24 hours a day to providers providers, pharmacies and pharmacies members to address pharmacy benefit questions and prior authorization requestsquestions. Please contact the Provider Line PCSC at 0-000-000-0000. A registered professional nurse or physician shall be immediately available by telephone seven days a week, 24 hours a day, seven days a week, to render utilization management determinations for providers. Presbyterian shall provide all members and providers with a toll-free telephone number by which to contact utilization management staff on at least a five-day, 40 hours a week basis. All members must have immediate telephone access seven days a week, 24 hours a day, seven days a week, to their Primary Care Physician or the physician’s authorized on-call back-up provider. When these providers are unavailable, a registered nurse or physician on the utilization management staff must be available to respond to inquiries concerning emergency or urgent care. In the event Medically Necessary Covered services are not reasonably available through participating healthcare professionals, Presbyterian shall allow the PCP or other participating healthcare professional to refer a member to a non-participating healthcare professional and shall fully reimburse the non-participating healthcare professional at the usual, customary, and reasonable rate or at an agreed-upon rate. Before Presbyterian may deny such a referral to a non- participating physician or healthcare professional, the request must be reviewed by a specialist similar to the type of specialist to whom a referral is requested.

Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; however, if you go to an Out-of-network (outside of the 5-county area) Pharmacy, and they are unable to process the claim at point of service you can may pay for the prescription and submit a Member Reimbursement Formmay request Presbyterian Health Plan to reimburse you. Reimbursement A Pharmacy Specialist will be review and process your request for reimbursement based on the negotiated rate between Presbyterian Health Plan and the dispensing pharmacy minus any copay or coinsurance that may apply. Members will not be liable to a provider for any sums owed to the provider by Presbyterian. The form together with Pharmacy Specialist needs the following information to determine reimbursement amounts. Please submit a Member Reimbursement Form and attach the itemized cash register receipt and the prescription drug detail (pharmacy pamphlet) must contain along with the following information: • Patient’s name Patient Name • Patient’s Date of Birth • Name of the drug • Quantity dispensed • NDC (National Drug Code) Code • Fill Date • Name of Prescriber • Name and phone number of the dispensing pharmacy • Reason for the purchase (nature of emergency) • Proof of Payment Member Reimbursement forms are available by calling our Presbyterian Customer Service Center, Monday through Friday, from 7 a.m. to 6 p.m. Center at (000) 000-0000 or 0-000-000-0000. , Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. Please follow the mailing instructions on the Member Reimbursement Form. A Pharmacy Services Call Center is available 24 hours a day to providers providers, pharmacies and pharmacies members to address pharmacy benefit questions and prior authorization requestsquestions. Please contact the Provider Line PCSC at 0-000-000-0000. A registered professional nurse or physician shall be immediately available by telephone 24 hours a day, seven days a week, to render utilization management determinations for providers. Presbyterian shall provide all members and providers with a toll-free telephone number by which to contact utilization management staff on at least a five-day, 40 hours a week basis. All members must have immediate telephone access 24 hours a day, seven days a week, to their Primary Care Physician or the physician’s authorized on-call back-up provider. When these providers are unavailable, a registered nurse or physician on the utilization management staff must be available to respond to inquiries concerning emergency or urgent care. In the event Medically Necessary Covered services are not reasonably available through participating healthcare professionals, Presbyterian shall allow the PCP or other participating healthcare professional to refer a member to a non-participating healthcare professional and shall fully reimburse the non-participating healthcare professional at the usual, customary, and reasonable rate or at an agreed-upon rate. Before Presbyterian may deny such a referral to a non- participating physician or healthcare professional, the request must be reviewed by a specialist similar to the type of specialist to whom a referral is requested.seven‌‌

Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; however, if you go to an Out-of-network (outside of the 5-county area) Pharmacy, and they are unable to process the claim at point of service you can pay for the prescription and submit a Member Reimbursement Form. Reimbursement will be based on the negotiated rate between Presbyterian Health Plan and the dispensing pharmacy minus any copay or coinsurance that may apply. The form together with the itemized cash register receipt and the prescription drug detail (pharmacy pamphlet) must contain the following information: • Patient’s name • Patient’s Date of Birth • Name of the drug • Quantity dispensed • NDC (National Drug Code) • Fill Date • Name of Prescriber • Name and phone number of the dispensing pharmacy • Reason for the purchase (nature of emergency) • Proof of Payment Member Reimbursement forms are available by calling our Presbyterian Customer Service Center, Monday through Friday, Friday from 7 a.m. to 6 p.m. at (000) 000-0000 or 0-000-000-0000. Hearing impaired users may call TTY 711. A The Presbyterian Health Plan Pharmacy Services Call Center Service Team is available 24 hours a day to providers and pharmacies to address pharmacy benefit questions and prior authorization Prior Authorization requests. Please contact the Provider Line at 0-000-000-0000. A registered professional nurse or physician shall be immediately available by telephone phone 24 hours a day, seven days a week, week to render utilization management determinations for providers. Presbyterian shall provide all members and providers with a toll-free telephone number by which to contact utilization management staff on at least a five-day, 40 hours a week basis. All members must have immediate telephone phone access 24 hours a day, seven days a week, week to their Primary Care Physician PCP or the physicianprovider’s authorized on-call back-up provider. When these providers are unavailable, a registered nurse or physician on the utilization management staff must be available to respond to inquiries concerning emergency or urgent careUrgent Care. In the event Medically Necessary Covered services are not reasonably available through participating healthcare professionals, Presbyterian shall allow the PCP or other participating healthcare professional to refer a member Member to a non-participating healthcare professional and shall fully reimburse the non-participating healthcare professional at the usual, customary, and reasonable rate or at an agreed-upon rate. Before Presbyterian may deny such a referral to a non- participating physician or healthcare professional, the request must be reviewed by a specialist similar to the type of specialist to whom a referral is requested.requested.‌‌‌‌

Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; however, if you go to an Out-of-network (outside of the 5-county area) Pharmacy, and they are unable to process the claim at the point of service you can may pay for the prescription and submit a Member Reimbursement Formmay request Presbyterian Insurance Company, Inc., reimburse you. Reimbursement A Pharmacy Specialist will be review and process your request for reimbursement based on the negotiated rate between Presbyterian Health Plan Insurance Company, Inc., and the dispensing pharmacy minus any copay or coinsurance that may apply. Members will not be liable to a provider for any sums owed to the provider by Presbyterian. The form together with Pharmacy Specialist needs the following information to determine reimbursement amounts. Please submit a Member Reimbursement Form and attach the itemized cash register receipt and the prescription drug detail (pharmacy pamphlet) must contain along with the following information: • Patient’s name • Patient’s Date of Birth • Name of the drug • Quantity dispensed • NDC (National Drug Code) • Fill Date • Name of Prescriber • Name and phone number of the dispensing pharmacy • Reason for the purchase (nature of emergency) • Proof of Payment Member Reimbursement forms are available by calling our Presbyterian Customer Service Center, Monday through Friday, from 7 a.m. to 6 p.m. Center at (000) 000-0000 or 0-000-000-0000. , Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call our TTY line at 711. Please follow the mailing instructions on the Member Reimbursement Form. A Pharmacy Services Call Center is available 24 hours a day to providers providers, pharmacies and pharmacies members to address pharmacy benefit questions and prior authorization requestsquestions. Please contact the Provider Line PCSC at 0-000-000-0000. A registered professional nurse or physician shall be immediately available by telephone seven days a week, 24 hours a day, seven days a week, to render utilization management determinations for providers. Presbyterian shall provide all members and providers with a toll-free telephone number by which to contact utilization management staff on at least a five-five day, 40 hours a week basis. All members must have immediate telephone access seven days a week, 24 hours a day, seven days a week, to their Primary Care Physician or the physician’s authorized on-call back-up provider. When these providers are unavailable, a registered nurse or physician on the utilization management staff must be available to respond to inquiries concerning emergency or urgent care. In the event Medically Necessary Covered services are not reasonably available through participating healthcare professionals, Presbyterian shall allow the PCP or other participating healthcare professional to refer a member to a non-participating healthcare professional and shall fully reimburse the non-participating healthcare professional at the usual, customary, and reasonable rate or at an agreed-upon rate. Before Presbyterian may deny such a referral to a non- participating physician or healthcare professional, the request must be reviewed by a specialist similar to the type of specialist to whom a referral is requested.

Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; however, if you go to an Out-of-network (outside of the 5-county area) Pharmacy, and they are unable to process the claim at point of service you can pay for the prescription and submit a Direct Member Reimbursement Formform. Reimbursement will be based on the negotiated rate between Presbyterian Health Plan and the dispensing pharmacy minus any copay or coinsurance that may apply. Members will not be liable to a Provider for any sums owed to the Provider by Presbyterian. The Pharmacy Specialist needs the following information to determine reimbursement amounts. Please submit a Direct Member Reimbursement form together with and attach the itemized cash register receipt and the prescription drug detail (pharmacy pamphlet) must contain along with the following information: • Patient’s name • Patient’s Date of Birth • Name of the drug • Quantity dispensed • NDC (National Drug Code) • Fill Date • Name of Prescriber • Name and phone number of the dispensing pharmacy • Reason for the purchase (nature of emergency) • Proof of Payment Member Reimbursement forms are available by calling our Presbyterian Customer Service Center, Monday through Friday, Friday from 7 a.m. to 6 p.m. at (000) 000-0000 or 0-000-000-0000. Hearing impaired users may call TTY 711. A The Presbyterian Health Plan Pharmacy Services Call Center Service Team is available 24 hours a day to providers and pharmacies to address pharmacy benefit questions and prior authorization requests. Please contact the Provider Line at (000) 000-0000 or 0-000-000-00000000 and follow the voice prompts and select Pharmacy. A registered professional nurse or physician shall be immediately available by telephone phone 24 hours a day, seven (7) days a week, week to render utilization management determinations for providers. Presbyterian shall provide all members and providers with a toll-free telephone phone number by which to contact utilization management staff on at least a five-day, 40 hours a week basis. All members must have immediate telephone phone access 24 hours a day, seven days a week, week to their Primary Care Physician PCP or the physicianprovider’s authorized on-call back-up provider. When these providers are unavailable, a registered nurse or physician on the utilization management staff must be available to respond to inquiries concerning emergency or urgent care. In the event Medically Necessary Covered services are not reasonably available through participating healthcare professionals, Presbyterian shall allow the PCP or other participating healthcare professional to refer a member Member to a non-participating healthcare professional and shall fully reimburse the non-participating healthcare professional at the usual, customary, and reasonable rate or at an agreed-upon rate. Before Presbyterian may deny such a referral to a non- participating physician or healthcare professional, the request must be reviewed by a specialist similar to the type of specialist to whom a referral is requested.

Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; however, if you go to an Out-of-network (outside of the 5-county area) Pharmacy, and they are unable to process the claim at point of service you can pay for the prescription and submit a Direct Member Reimbursement Formform. Reimbursement will be based on the negotiated rate between Presbyterian Health Plan and the dispensing pharmacy minus any copay or coinsurance that may apply. Members will not be liable to a Provider for any sums owed to the Provider by Presbyterian. The Pharmacy Specialist needs the following information to determine reimbursement amounts. Please submit a Direct Member Reimbursement form together with and attach the itemized cash register receipt and the prescription drug detail (pharmacy pamphlet) must contain along with the following information: • Patient’s name • Patient’s Date of Birth • Name of the drug • Quantity dispensed • NDC (National Drug Code) • Fill Date • Name of Prescriber • Name and phone number of the dispensing pharmacy • Reason for the purchase (nature of emergency) • Proof of Payment Member Reimbursement forms are available by calling our Presbyterian Customer Service Center, Monday through Friday, Friday from 7 a.m. to 6 p.m. at (000) 000-0000 or 0-000-000-0000. Hearing impaired users may call TTY 711. A The Presbyterian Health Plan Pharmacy Services Call Center Service Team is available 24 hours a day to providers and pharmacies to address pharmacy benefit questions and prior authorization requests. Please contact the Provider Line at (000) 000-0000 or 0-000-000-00000000 and follow the voice prompts and select Pharmacy. A registered professional nurse or physician shall be immediately available by telephone phone 24 hours a day, seven days a week, week to render utilization management determinations for providers. Presbyterian shall provide all members and providers with a toll-free telephone phone number by which to contact utilization management staff on at least a five-day, 40 hours a week basis. All members must have immediate telephone phone access 24 hours a day, seven days a week, week to their Primary Care Physician PCP or the physicianprovider’s authorized on-call back-up provider. When these providers are unavailable, a registered nurse or physician on the utilization management staff must be available to respond to inquiries concerning emergency or urgent care. In the event Medically Necessary Covered services are not reasonably available through participating healthcare professionals, Presbyterian shall allow the PCP or other participating healthcare professional to refer a member Member to a non-participating healthcare professional and shall fully reimburse the non-participating healthcare professional at the usual, customary, and reasonable rate or at an agreed-upon rate. Before Presbyterian may deny such a referral to a non- participating physician or healthcare professional, the request must be reviewed by a specialist similar to the type of specialist to whom a referral is requested. Proton Beam Irradiation‌‌‌‌‌ Proton Beam Therapy is a type of radiation that utilizes protons to deliver ionizing damage to a target. Proton Beam Irradiation requires Prior Authorization.

Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; however, if you go to an Out-of-network (outside of the 5-county area) Pharmacy, and they are unable to process the claim at the point of service you can may pay for the prescription and submit a Member Reimbursement Formmay request Presbyterian Insurance Company, Inc., reimburse you. Reimbursement A Pharmacy Specialist will be review and process your request for reimbursement based on the negotiated rate between Presbyterian Health Plan Insurance Company, Inc., and the dispensing pharmacy minus any copay or coinsurance that may apply. Members will not be liable to a provider for any sums owed to the provider by Presbyterian. The form together with Pharmacy Specialist needs the following information to determine reimbursement amounts. Please submit a Member Reimbursement Form and attach the itemized cash register receipt and the prescription drug detail (pharmacy pamphlet) must contain along with the following information: • Patient’s name • Patient’s Date of Birth • Name of the drug • Quantity dispensed • NDC (National Drug Code) • Fill Date • Name of Prescriber • Name and phone number of the dispensing pharmacy • Reason for the purchase (nature of emergency) • Proof of Payment Member Reimbursement forms are available by calling our Presbyterian Customer Service Center, Monday through Friday, from 7 a.m. to 6 p.m. Center at (000) 000-0000 or 0-000-000-0000. , Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. Please follow the mailing instructions on the Member Reimbursement Form. A Pharmacy Services Call Center is available 24 hours a day to providers providers, pharmacies and pharmacies members to address pharmacy benefit questions and prior authorization requestsquestions. Please contact the Provider Line PCSC at 0-000-000-0000. A registered professional nurse or physician shall be immediately available by telephone 24 hours a day, seven days a week, to render utilization management determinations for providers. providers.‌ Presbyterian shall provide all members and providers with a toll-free telephone number by which to contact utilization management staff on at least a five-five day, 40 hours a week basis. All members must have immediate telephone access 24 hours a day, seven days a week, to their Primary Care Physician or the physician’s authorized on-call back-up provider. When these providers are unavailable, a registered nurse or physician on the utilization management staff must be available to respond to inquiries concerning emergency or urgent care. In the event Medically Necessary Covered services are not reasonably available through participating healthcare professionals, Presbyterian shall allow the PCP or other participating healthcare professional to refer a member to a non-participating healthcare professional and shall fully reimburse the non-participating healthcare professional at the usual, customary, and reasonable rate or at an agreed-upon rate. Before Presbyterian may deny such a referral to a non- participating physician or healthcare professional, the request must be reviewed by a specialist similar to the type of specialist to whom a referral is requested.

Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; however, if you go to an Out-of-network (outside of the 5-county area) Pharmacy, and they are unable to process the claim at point of service you can may pay for the prescription and submit a Member Reimbursement Formmay request Presbyterian Health Plan to reimburse you. Reimbursement A Pharmacy Specialist will be review and process your request for reimbursement based on the negotiated rate between Presbyterian Health Plan and the dispensing pharmacy minus any copay or coinsurance that may apply. Members will not be liable to a provider for any sums owed to the provider by Presbyterian. The form together with Pharmacy Specialist needs the following information to determine reimbursement amounts. Please submit a Member Reimbursement Form and attach the itemized cash register receipt and the prescription drug detail (pharmacy pamphlet) must contain along with the following information: • Patient’s name Name • Patient’s Date of Birth • Name of the drug • Quantity dispensed • NDC (National Drug Code) Code • Fill Date • Name of Prescriber • Name and phone number of the dispensing pharmacy • Reason for the purchase (nature of emergency) • Proof of Payment Member Reimbursement forms are available by calling our Presbyterian Customer Service Center, Monday through Friday, from 7 a.m. to 6 p.m. Center at (000) 000-0000 or 0-000-000-0000. , Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. A Please follow the mailing instructions on the Member Reimbursement Form.‌ The Presbyterian Health Plan Pharmacy Services Call Center Service Team is available 24 hours a day to providers providers, pharmacies, and pharmacies Members to address pharmacy benefit questions and prior authorization requestsquestions. Please contact the Provider Line them at (000) 000-0000 or 0-000-000-00000000 (select option 6 when calling either number). A registered professional nurse or physician shall be immediately available by telephone phone 24 hours a day, seven days a week, week to render utilization management determinations for providers. Presbyterian shall provide all members and providers with a toll-free telephone phone number by which to contact utilization management staff on at least a five-day, 40 hours a week basis. All members must have immediate telephone phone access 24 hours a day, seven days a week, week to their Primary Care Physician PCP or the physicianprovider’s authorized on-call back-up provider. When these providers are unavailable, a registered nurse or physician on the utilization management staff must be available to respond to inquiries concerning emergency or urgent care. In the event Medically Necessary Covered medically necessary covered services are not reasonably available through participating healthcare professionals, Presbyterian shall allow the PCP or other participating healthcare professional to refer a member Member to a non-participating healthcare professional and shall fully reimburse the non-participating healthcare professional at the usual, customary, and reasonable rate or at an agreed-upon rate. Before Presbyterian may deny such a referral to a non- participating physician or healthcare professional, the request must be reviewed by a specialist similar to the type of specialist to whom a referral is requested.

Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; however, if you go to an Out-of-network (outside of the 5-county area) Pharmacy, and they are unable to process the claim at the point of service you can may pay for the prescription and submit a Member Reimbursement Formmay request Presbyterian Insurance Company to reimburse you. Reimbursement A Pharmacy Specialist will be review and process your request for reimbursement based on the negotiated rate between Presbyterian Health Plan Insurance Company and the dispensing pharmacy minus any copay or coinsurance that may apply. Members will not be liable to a provider for any sums owed to the provider by Presbyterian. The form together with Pharmacy Specialist needs the following information to determine reimbursement amounts. Please submit a Member Reimbursement Form and attach the itemized cash register receipt and the prescription drug detail (pharmacy pamphlet) must contain along with the following information: • Patient’s name • Patient’s Date of Birth • Name of the drug • Quantity dispensed • NDC (National Drug Code) • Fill Date • Name of Prescriber • Name and phone number of the dispensing pharmacy • Reason for the purchase (nature of emergency) • Proof of Payment payment Member Reimbursement forms are available by calling our Presbyterian Customer Service Center, Monday through Friday, from 7 a.m. to 6 p.m. Center at (000) 000-0000 or 0-000-000-0000. , Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. A Please follow the mailing instructions on the Member Reimbursement Form. The Presbyterian Health Plan Pharmacy Services Call Center Service Team is available 24 hours a day to providers providers, pharmacies and pharmacies members to address pharmacy benefit questions and prior authorization requestsquestions. Please contact the Provider Line them at (000) 000-0000 or 0-000-000-00000000 (select option 6 when calling either number). A registered professional nurse or physician shall be immediately available by telephone 24 hours a day, seven days a week, to render utilization management determinations for providers. Presbyterian shall provide all members and providers with a toll-free telephone number by which to contact utilization management staff on at least a five-day, 40 hours a week basis. All members must have immediate telephone access 24 hours a day, seven days a week, to their Primary Care Physician PCP or the physician’s authorized on-call back-up provider. When these providers are unavailable, a registered nurse or physician on the utilization management staff must be available to respond to inquiries concerning emergency or urgent care. In the event Medically Necessary Covered services are not reasonably available through participating healthcare professionals, Presbyterian shall allow the PCP or other participating healthcare professional to refer a member to a non-participating healthcare professional and shall fully reimburse the non-participating healthcare professional at the usual, customary, and reasonable rate or at an agreed-upon rate. Before Presbyterian may deny such a referral to a non- participating physician or healthcare professional, the request must be reviewed by a specialist similar to the type of specialist to whom a referral is requested.

Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; however, if you go to an Out-of-network (outside of the 5-county area) Pharmacy, and they are unable to process the claim at point of service you can may pay for the prescription and submit a Member Reimbursement Formmay request Presbyterian Health Plan to reimburse you. Reimbursement A Pharmacy Specialist will be review and process your request for reimbursement based on the negotiated rate between Presbyterian Health Plan and the dispensing pharmacy minus any copay or coinsurance that may apply. Members will not be liable to a provider for any sums owed to the provider by Presbyterian. The form together with Pharmacy Specialist needs the following information to determine reimbursement amounts. Please submit a Member Reimbursement Form and attach the itemized cash register receipt and the prescription drug detail (pharmacy pamphlet) must contain along with the following information: • Patient’s name Name • Patient’s Date of Birth • Name of the drug • Quantity dispensed • NDC (National Drug Code) Code • Fill Date • Name of Prescriber • Name and phone number of the dispensing pharmacy • Reason for the purchase (nature of emergency) • Proof of Payment Member Reimbursement forms are available by calling our Presbyterian Customer Service Center, Monday through Friday, from 7 a.m. to 6 p.m. Center at (000) 000-0000 or 0-000-000-0000. , Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. A Please follow the mailing instructions on the Member Reimbursement Form. The Presbyterian Health Plan Pharmacy Services Call Center Service Team is available 24 hours a day to providers providers, pharmacies, and pharmacies Members to address pharmacy benefit questions and prior authorization requestsquestions. Please contact the Provider Line them at (000) 000-0000 or 0-000-000-0000. 0000 (select option 6 when calling either number).‌ A registered professional nurse or physician shall be immediately available by telephone phone 24 hours a day, seven days a week, week to render utilization management determinations for providers. Presbyterian shall provide all members and providers with a toll-free telephone phone number by which to contact utilization management staff on at least a five-day, 40 hours a week basis. All members must have immediate telephone phone access 24 hours a day, seven days a week, week to their Primary Care Physician PCP or the physicianprovider’s authorized on-call back-up provider. When these providers are unavailable, a registered nurse or physician on the utilization management staff must be available to respond to inquiries concerning emergency or urgent careUrgent Care. In the event Medically Necessary Covered medically necessary covered services are not reasonably available through participating healthcare professionals, Presbyterian shall allow the PCP or other participating healthcare professional to refer a member Member to a non-participating healthcare professional and shall fully reimburse the non-participating healthcare professional at the usual, customary, and reasonable rate or at an agreed-upon rate. Before Presbyterian may deny such a referral to a non- participating physician or healthcare professional, the request must be reviewed by a specialist similar to the type of specialist to whom a referral is requested.

Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; however, if you go to an Out-of-network (outside of the 5-county area) Pharmacy, and they are unable to process the claim at point of service you can pay for the prescription and submit a Member Reimbursement Form. Reimbursement will be based on the negotiated rate between Presbyterian Health Plan and the dispensing pharmacy minus any copay or coinsurance that may apply. Members will not be liable to a provider for any sums owed to the provider by Presbyterian. The form together with Pharmacy Specialist needs the following information to determine reimbursement amounts. Please submit a Member Reimbursement Form and attach the itemized cash register receipt and the prescription drug detail (pharmacy pamphlet) must contain along with the following information: • Patient’s name • Patient’s Date of Birth • Name of the drug • Quantity dispensed • NDC (National Drug Code) • Fill Date • Name of Prescriber • Name and phone number of the dispensing pharmacy • Reason for the purchase (nature of emergency) • Proof of Payment Member Reimbursement forms are available by calling our Presbyterian Customer Service Center, Monday through Friday, Friday from 7 a.m. to 6 p.m. at (000) 000-0000 or 0-000-000-0000. Hearing impaired users may call TTY 711. A The Presbyterian Health Plan Pharmacy Services Call Center Service Team is available 24 hours a day to providers and pharmacies to address pharmacy benefit questions and prior authorization requests. Please contact the Provider Line at 0-000-000-0000. A registered professional nurse or physician shall be immediately available by telephone phone 24 hours a day, seven days a week, week to render utilization management determinations for providers. Presbyterian shall provide all members and providers with a toll-free telephone phone number by which to contact utilization management staff on at least a five-day, 40 hours a week basis. All members must have immediate telephone phone access 24 hours a day, seven days a week, week to their Primary Care Physician PCP or the physicianprovider’s authorized on-call back-up provider. When these providers are unavailable, a registered nurse or physician on the utilization management staff must be available to respond to inquiries concerning emergency or urgent care. care.‌‌‌ In the event Medically Necessary Covered services are not reasonably available through participating healthcare professionals, Presbyterian shall allow the PCP or other participating healthcare professional to refer a member Member to a non-participating healthcare professional and shall fully reimburse the non-participating healthcare professional at the usual, customary, and reasonable rate or at an agreed-upon rate. Before Presbyterian may deny such a referral to a non- participating physician or healthcare professional, the request must be reviewed by a specialist similar to the type of specialist to whom a referral is requested.