Common use of Non-Plan Pharmacy Benefit Payments Clause in Contracts

Non-Plan Pharmacy Benefit Payments. In order for claims for Covered Drugs obtained at a Non-Plan Pharmacy to be eligible for benefit payment, the Insured must complete and submit a Pharmacy Reimbursement Claim Form with the prescription label and register receipt to SHL or its designee. Benefit payments are subject to the limitations and exclusions set forth in the SHL AOC as follows: 1. When any Covered Drug is dispensed, the benefit payment will be subject to SHL’s EME and any applicable tier Copayment and/or Coinsurance. The Insured is responsible for any amounts exceeding SHL’s benefit payment. 2. The Mandatory Generic benefit provision applies when any Brand Name Covered Drug is dispensed and a Generic Covered Drug equivalent is available. The benefit payment is subject to SHL’s EME of the Generic Covered Drug less the applicable tier Copayment and/or Coinsurance. The Insured is responsible for any amounts exceeding SHL’s benefit payment. 3. No benefits are payable if SHL’s EME of the Covered Drug is less than the applicable Copayment and/or Coinsurance.

Non-Plan Pharmacy Benefit Payments. In order for claims for Covered Drugs obtained at a Non-Plan Pharmacy to be eligible for benefit payment, the Insured must complete and submit a Pharmacy Reimbursement Claim Form with the prescription label and register receipt to SHL or its designee. Benefit payments are subject to the limitations and exclusions set forth in the SHL AOC as follows: 1. When any Covered Drug is dispensed, the benefit payment will be subject to SHL’s EME and any applicable tier Copayment and/or CoinsuranceTier I, II, III or IV Cost- share. The Insured is responsible for any amounts exceeding SHL’s benefit payment. 2. The Mandatory Generic benefit provision applies when any Brand Name Covered Drug is dispensed and a Generic Covered Drug equivalent is available. The benefit payment is subject to SHL’s EME of the Generic Covered Drug less the applicable tier Copayment and/or Coinsurancecopayment. The Insured is responsible for any amounts exceeding SHL’s benefit payment. 3. No benefits are payable if SHL’s EME of the Covered Drug is less than the applicable Copayment and/or CoinsuranceCost-share.