Negotiated Charge. As to health care coverage, other than Prescribed Medicine Expense coverage: The maximum charge a preferred care provider has agreed to make as to any service or supply for the purpose of the benefits under the Policy. As to Prescribed Medicine Expense coverage: The negotiated charge is the amount Aetna has established for each prescription drug obtained from a preferred pharmacy under the Policy. This negotiated charge may reflect amounts Aetna has agreed to pay directly to the preferred pharmacy or to a third party vendor for the prescription drug, and may include an additional service or risk charge set by Aetna. The negotiated charge does not include or reflect any amount Aetna, an affiliate, or a third party vendor, may receive under a rebate arrangement between Aetna, an affiliate or a third party vendor and a drug manufacturer for any prescription drug, including prescription drugs on the medication formulary. Based on its overall drug purchasing, Aetna may receive rebates from the manufacturers of prescription drugs and may receive or pay additional amounts from or to third parties underprice guarantees. These amounts will not change the negotiated charge under the Policy. Network Provider A health care provider, pharmacy, or dental provider who has contracted to furnish services or supplies for a negotiated charge; but only if the provider is, with Aetna's consent, included in xxx.xxxxxxx.xxx as a network provider for: • The service or supply involved; and • The class of employees to which the covered person belongs. Network Service(s) or Supply(ies) Health care service or supply that is furnished by a network provider.
Negotiated Charge. For health coverage: This is the amount a network provider has agreed to accept or that we have agreed to pay them or a third-party vendor (including any administrative fee in the amount paid). We may enter into arrangements with network providers or others related to: • The coordination of care for members • Improving clinical outcomes and efficiencies Some of these arrangements are called: • Value-based contracting • Risk sharing • Accountable care arrangements These arrangements will not change the negotiated charge under this plan. For prescription drug services: When you get a prescription drug, we have agreed to this amount for the prescription or paid this amount to the network pharmacy or third-party vendor that provided it. The negotiated charge may include a rebate, additional service or risk charges and administrative fees. It may include additional amounts paid to or received from third parties under price guarantees. Surprise bill There may be times when you unknowingly receive services or don’t consent to receive services from an out-of-network provider, even when you try to stay in the network for your covered services. You may get a bill at the out-of-network rate that you didn’t expect. This is called a surprise bill. An out-of-network provider can’t balance bill or attempt to collect costs from you that exceed your in- network cost-sharing requirement, such as deductibles, copayments and coinsurance for the following services: • Emergency services provided by an out-of-network provider • Non-emergency surgical or ancillary services provided by an out-of-network provider at an in- network facility, except when the out-of-network provider has given you the following: ‒ The out-of-network notice for your signature ‒ The estimated charges for the items and services ‒ Notice that the provider is an out-of-network provider • Out-of-network air ambulance services The out-of-network provider must get your consent to be treated and balance billed by them. Surgical or ancillary services mean any professional services including: • Anesthesiology • Hospitalist services • Laboratory services • Pathology • Radiology • Surgery
Negotiated Charge. As to the coverage provided under this Prescription Plan Rider, the amount HMO has established for each prescription drug obtained from a Participating Retail, Mail Order, or Specialty Pharmacy Network Pharmacy. The Negotiated Charge may reflect amounts HMO has agreed to pay directly to the Participating Retail, Mail Order, or Specialty Pharmacy Network Pharmacy, or to a third party vendor for the prescription drug, and may include an additional service or risk charge set by HMO. The Negotiated Charge does not include or reflect any amount HMO, an affiliate, or a third party vendor, may receive under a rebate arrangement between HMO, an affiliate or a third party vendor and a drug manufacturer for any prescription drug, including prescription drugs on the Drug Formulary. Based on its overall drug purchasing, HMO may receive rebates from the manufacturers of prescription drugs and may receive or pay additional amounts from or to third parties under price guarantees. These amounts will not change the Negotiated Charge under this Prescription Plan Rider. • Non-Formulary Prescription Drug(s). A product or drug not listed on the Drug Formulary which includes drugs listed on the Drug Formulary Exclusions List. • Participating Mail Order Pharmacy. A pharmacy, which has contracted with HMO, an affiliate, or a third party vendor, to provide covered outpatient prescription drugs or medicines, and insulin to Members by mail or other carrier.
Negotiated Charge. This is the maximum charge a Preferred Care Provider has agreed to make as to any service or supply for the purpose of the benefits under the Plan.
