Non-Participating Pharmacy Sample Clauses

Non-Participating Pharmacy. A Pharmacy with which CHPW does not have a contract, including contracted access to any network to which the Pharmacy belongs. Non-Participating Pharmacies may not be able to or may choose not to submit Claims electronically.

Non-Participating Pharmacy you must pay for the prescription in full and then submit a claim form for reimbursement. Blue Shield will reimburse you as shown on the Summary of Benefits, based on the price you paid for the Drugs. See the Claims section under Your payment information for more information. You have an option to receive prescription Drugs from the mail service pharmacy when you take maintenance Drugs for an ongoing condition. This allows you to receive up to a 90-day supply of the Drug, which may save you money. You may enroll in this program online, by phone, or by mail. Once enrolled, please allow up to 14 days to receive the Drug. If your Physician or Health Care Provider submits a prescription for less than a 90-day supply, the mail service pharmacy will only dispense the amount prescribed. Specialty Drugs are not available from the mail service pharmacy. You must pay the applicable mail service prescription Drug Copayment or Coinsurance for each prescription Drug. Visit xxxxxxxxxxxx.xxx or use the Blue Shield mobile app for additional information about how to get prescription Drugs from the mail service pharmacy.

Non-Participating Pharmacy. A Network Specialty Pharmacy offers 24-hour clinical ser- vices, coordination of care with Physicians, and reporting of certain clinical events associated with select Drugs to the FDA. To select a Network Specialty Pharmacy, you may go to xxxx://xxx.xxxxxxxxxxxx.xxx or call Customer Service. Go to xxxx://xxx.xxxxxxxxxxxx.xxx for a complete list of Specialty Drugs. Most Specialty Drugs require prior autho- rization for Medical Necessity by Blue Shield, as described in the Prior Authorization/Exception Request Process/Step Therapy section. Some Drugs and Drug quantities require prior approval for Medical Necessity before they are eligible for coverage un- der the Outpatient Prescription Drug Benefit. This process is called prior authorization. The following Drugs require prior authorization:  Some Formulary, compound Drugs, and most Specialty Drugs require prior authorization.  Drugs exceeding the maximum allowable quantity based on Medical Necessity and appropriateness of ther- apy.  Brand contraceptives may require prior authorization to be covered without a Copayment or Coinsurance. Blue Shield covers compounded medication(s) when:  The compounded medication(s) include at least one Drug,  There are no FDA-approved, commercially available, medically appropriate alternative,  The compounded medication is self-administered, and  Medical literature supports its use for the diagnosis. You must pay the Tier 3 Copayment or Coinsurance for cov- ered compound Drugs. You, your Physician or Health Care Provider may request prior authorization for the Drugs listed above by submitting supporting information to Blue Shield. Once Blue Shield re- ceives all required supporting information, we will provide prior authorization approval or denial, based upon Medical Necessity, within 72 hours in routine circumstances or 24 hours in exigent circumstances. Exigent circumstances exist when a Member has a health condition that may seriously jeopardize the Member’s life, health, or ability to regain maximum function or when a Member is undergoing a cur- rent course of treatment using a Non-Formulary Drug. To request coverage for a Non-Formulary Drug, you, your representative or Health Care Provider may submit an excep- tion request to Blue Shield. Once all required supporting in- formation is received, Blue Shield will approve or deny the exception request, based upon Medical Necessity, within 72 hours in routine circumstances or 24 hours in exigent circum- stances. Step ...

Non-Participating Pharmacy. Any Pharmacy other than a Participating Pharmacy which regularly sells Prescription Drugs.

Non-Participating Pharmacy. A Network Specialty Pharmacy offers 24-hour clinical services, coordination of care with Physicians, and reporting of certain clinical events associated with select Drugs to the FDA. To select a Network Specialty Pharmacy, the Member may go to xxxx://xxx.xxxxxxxxxxxx.xxx or call Shield Concierge. Go to xxxx://xxx.xxxxxxxxxxxx.xxx for a complete list of Specialty Drugs. Most Specialty Drugs require prior authorization for Medical Necessity by Blue Shield, as described in the Prior Authorization/Exception Request Process section. Some Drugs and Drug quantities require prior approval for Medical Necessity before they are eligible to be covered by the Outpatient Prescription Drug Benefit. This process is called prior authorization. The following Drugs require prior authorization:

Non-Participating Pharmacy. Any registered, licensed pharmacy with whom Our pharmacy benefit administrator or We do not have a contract.

Non-Participating Pharmacy. A Network Specialty Pharmacy offers 24-hour clinical ser- vices, coordination of care with Physicians, and reporting of certain clinical events associated with select Drugs to the FDA. To select a Network Specialty Pharmacy, you may go to xxxx://xxx.xxxxxxxxxxxx.xxx or call Customer Service. Go to xxxx://xxx.xxxxxxxxxxxx.xxx for a complete list of Specialty Drugs. Most Specialty Drugs require prior autho- rization for Medical Necessity by Blue Shield, as described in the Prior Authorization/Exception Request Process/Step Therapy section.

Non-Participating Pharmacy. If you choose to visit a Non-Network pharmacy and the pharmacy is willing to accept reimbursement at the same rates as a participating pharmacy, they can submit a request for reimbursement to Us. Contact us at 0-000-000-0000 if you and your pharmacy wish to pursue this option. Some medications, despite being prescribed by your Healthcare Provider, require an additional review by a Clinician before you can fill the prescription. This process is called Prior Authorization. A Clinician performs a Prior Authorization review to ensure the prescribed drug is safe, effective, and appropriate for your specific treatment plan. A list of the medications which require a Prior Authorization and the required forms are available on our website at xxx.xxxxxxx.xxx or by contacting member services at 1-855- 672-2789. We will review all Prior Authorization requests and make a decision to approve or deny coverage for the requested medication based on established clinical criteria. A decision will be made within the time limits specified by State or NCQA Regulations. If you or Your Health Care Provider do not agree with the decision made by Us, you have the ability to contest the decision (see ""When you disagree'). If your health care provider does not obtain a Prior Authorization, the pharmacy will be alerted when they are attempting to submit a claim to Us and you will not be able to receive your medication. Certain medications are subject to step therapy requirements. This means that in order to receive benefits for such medications you are required to try a different medication first unless you satisfy the plan’s exception criteria. You may identify whether a particular medication is subject to step therapy requirements at xxx.xxxxxxx.xxx or by contacting member services at 0-000-000-0000. A step therapy exception will be granted if Your prescribing Provider submits justification and supporting clinical documentation, if needed, is completed and determined to support such provider's statement that: • The required prescription drug is contraindicated or will cause an adverse reaction or physical or mental harm to the patient; • The required prescription drug is expected to be ineffective based on Your known clinical condition and the known characteristics of the prescription drug regimen; • You have tried the required prescription drug or another prescription drug in the same pharmacological class or with the same mechanism of action as the required drug while on this Pla...

Non-Participating Pharmacy. If you have a Prescription Order filled at a Non- Participating Pharmacy, you must pay the Pharmacy the full amount of its bill and submit to Blue Cross and Blue Shield a Claim form and itemized receipt veri- fying that the prescription was filled. Blue Cross and Blue Shield will reimburse you for Covered Drugs equal to: S the Coinsurance Amount or Copayment Amount indicated on your Schedule Page, S less any deductible, S less any pricing differences that may apply to the Covered Drug you receive. The mail- order Pharmacy provides delivery of Covered Drugs directly to your home address. If you and your covered dependents elect to use the mail- order service, refer to your Schedule Page for applicable payment levels. All items that are covered under the mail- order Pharmacy are the same items that are covered under retail Pharmacy and are subject to the same limitations and exclusions. Items covered through a specialty Phar- macy will not be covered through the mail- order Pharmacy. NOTE: Prescription drugs and other items may not be mailed outside the United States. The mail- order Pharmacy has been selected to fill and deliver maintenance (long- term) medications. In order to receive maximum benefits you must obtain these maintenance medications through mail order. Some drugs may not be available through the mail- order Pharmacy. If you have any questions about this mail- order service, need assistance in determining the amount of your payment, or need to obtain the mail- order prescription form, you may access the website at xxx.xxxxxx.xxx or contact Customer Service at the toll- free number on your Identification Card. Mail the completed form, your Prescription Order(s) and pay- ment to the address indicated on the form. If you send an incorrect payment amount for the Covered Drug dispensed, you will: (a) receive a credit if the payment is too much; or (b) be billed for the appropriate amount if it is not enough.