Note to carriers. If a carrier elects to include audit procedures in the policy, include your specific audit procedures as an additional paragraph.] [We will not restrict or prohibit, directly or indirectly, a Participating Pharmacy [or a Participating Mail Order Pharmacy] from charging the Member for charges that are in addition to charges for the Prescription Drug, for dispensing the Prescription Drug or for prescription counseling provided such other charges have been approved by the New Jersey Board of Pharmacy, and the amount of the charges for the additional services and the purchaser's out-of-pocket cost for those services has been disclosed to the Member prior to dispensing the drug.] [Specialty Pharmaceuticals Split Fill Program: Select Specialty Drugs will be eligible for a split fill when a new prescription that will be filled at a specialty pharmacy is prescribed. Under the split fill program an initial prescription will be dispensed in two separate amounts. The first shipment will be for a 15-day supply. The [Member] will be contacted prior to dispensing the second 15-day supply in order to evaluate necessary clinical intervention due to medication side effects that may require a dose modification or discontinuation of the medication. The split-fill process will continue for the first 90 days the [Member] takes the medication. The [Member’s] cost share (Copayment) amounts will be prorated to align with the quantity dispensed with each fill. If the [Member] does not wish to have a split fill of the medication, he or she may decline participation in the program. For those [Members] the Specialty Pharmacy will ship the full prescription amount and charge the [Member] the cost share for the medication dispensed. Alternatively, the [Member] may obtain the medication at a retail pharmacy.]
Note to carriers. Carriers may include information regarding the pharmacy benefit manager, quantity and supply limit rules, appeals procedures and policies regarding refills and vacation overrides.]
Note to carriers. Carriers may include information regarding the pharmacy benefit manager, quantity and supply limit rules, appeals procedures and policies regarding refills and vacation overrides.] [As explained in the Orally Administered Anti-Cancer Prescription Drugs provision below additional benefits for such prescription drugs may be payable.]
Note to carriers. If a carrier elects to include audit procedures in the policy, include your specific audit procedures as an additional paragraph.] [We will not restrict or prohibit, directly or indirectly, a Participating Pharmacy [or a Participating Mail Order Pharmacy] from charging the Member for charges that are in addition to charges for the Prescription Drug, for dispensing the Prescription Drug or for prescription counseling provided such other charges have been approved by the New Jersey Board of Pharmacy, and the amount of the charges for the additional services and the purchaser's out-of-pocket cost for those services has been disclosed to the Member prior to dispensing the drug.]
Note to carriers. Carriers may place the taglines in the location the carrier believes most appropriate. TABLE OF CONTENTS Section Page SCHEDULE OF PREMIUM RATES AND CLASSIFICATION SCHEDULE OF SERVICES AND SUPPLIES DEFINITIONS ELIGIBILITY [MEMBER] PROVISIONS [COVERAGE PROVISION] COVERED SERVICES AND SUPPLIES NON-COVERED SERVICES AND SUPPLIES COORDINATION OF BENEFITS AND SERVICES GENERAL PROVISIONS CONTINUATION RIGHTS MEDICARE AS SECONDARY PAYOR SCHEDULE OF PREMIUM RATES AND CLASSIFICATION [The monthly premium rates, in U.S. dollars, for the coverage provided under this Contract are set forth on the [rate quote] for this Contract for the effective date shown on the face page of the Contract. We have the right to prospectively change any Premium rate(s) set forth above at the times and in the manner established by the provision of this Contract entitled " General Provisions." ____________________________________ This Contract’s classifications, and the coverages and amounts which apply to each class are shown below: CLASS(ES) [All eligible employees] SCHEDULE OF SERVICES AND SUPPLIES [Using Copayment] THE SERVICES OR SUPPLIES COVERED UNDER THIS CONTRACT ARE SUBJECT TO ALL COPAYMENTS [AND COINSURANCE] AND ARE DETERMINED PER [CALENDAR] [PLAN] YEAR PER [MEMBER], UNLESS OTHERWISE STATED. MAXIMUMS ONLY APPLY TO THE SPECIFIC SERVICES PROVIDED. [SERVICES COPAYMENTS[/COINSURANCE]: HOSPITAL SERVICES: INPATIENT [$100 to $500] Copayment/day for a maximum of 5 days/admission. Maximum Copayment [dollar amount equal to 10 times the per day copayment ]/[Calendar] [Plan] Year. Unlimited days. OUTPATIENT [amount consistent with N.J.A.C. 11:22-5.5(a)] ] Copayment/visit PRACTITIONER SERVICES RECEIVED AT A HOSPITAL: INPATIENT VISIT $0 Copayment OUTPATIENT VISIT [amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment/visit; no Copayment if any other Copayment applies. EMERGENCY ROOM [at the option of the carrier,$50, $75 or $100] Copayment/visit/Member (credited toward Inpatient Admission if Admission occurs within 24 hours) Note: The Emergency Room Copayment is payable in addition to the applicable Copayment and Coinsurance, if any. [URGENT CARE [amount consistent with N.J.A.C. 11:22-5.5(a)]] SURGERY:. INPATIENT $0 Copayment OUTPATIENT [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit HOME HEALTH CARE 60 visits, if Pre-Approved; amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment per [day] [visit]. HOSPICE SERVICES Unlimited days, if Pre-Approved; $0 Copayment. MATERNITY (PRE-...
Note to carriers. Use the above text for other than single coverage for a plan that is a high deductible health plan that could be used in conjunction with an HSA. Maximum Out of Pocket Maximum out of pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all Covered Services or Supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the Maximum Out of Pocket. Once the Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for Covered Services or Supplies for the remainder of the Calendar Year. Once Members in a family meet the family Maximum Out of Pocket, no other Member in that family will be required to pay any amounts as Copayments, Deductible or Coinsurance for Covered Services and Supplies for the remainder of the Calendar Year. [Tier 1] and [Tier 2] Maximum Out of Pocket [Please note: There are separate Maximum Out of Pocket amounts for [Tier 1] and [Tier 2] as shown on the Schedule.] [Tier 1] Network Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all [Tier 1] Network Covered Services and Supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the [Tier 1] Network Maximum Out of Pocket. Once the [Tier 1] Network Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for [Tier 1] Network Covered Services and Supplies for the remainder of the Calendar Year. Once any combination of Members in a family meet an amount equal to two times the [Tier 1] individual Maximum Out of Pocket, no Member in that family will be required to pay any amounts as Copayments, Deductible or Coinsurance for [Tier 1] Network Covered Services and Supplies for the remainder of the Calendar Year. [Tier 2] Network Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all [Tier 2] Network Covered Services and Supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the [Tier 2] Network Maximum Out of Pocket. Once the [Tier 2] Network Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for [Tier ...
Note to carriers. This exclusion for abortion is only to be included in a policy issued to a religious employer granted such an exclusion. A “religious employer” means an organization that is organized and operates as a nonprofit entity and is referred to in section 6033(a)(3)(A)(i) or (iii) of the Internal 10 Revenue Code of 1986 (26 U.S.C. s.6033), as amended.] Care or treatment by means of acupuncture except when used as a substitute for other forms of anesthesia. The amount of any charge which is greater than an Allowed Charge. Services for ambulance for transportation from a Hospital or other health care Facility, unless [Member] is being transferred to another Inpatient health care Facility. [Broken Appointments.] Blood or blood plasma which is replaced by or for a[Member]. Care and/or treatment by a Christian Science Practitioner. Completion of claim forms. [Preventive contraceptive services and supplies that are rated “A” or “B” by the United States Preventive Services Task Force shall be excluded from this Policy if the Policyholder is a Religious Employer or and Eligible Organization as defined under 45 C.F.R. 147.131, as amended] Services or supplies related to Cosmetic Surgery, except as otherwise stated in this Contract; complications of Cosmetic Surgery; drugs prescribed for cosmetic purposes Services related to Custodial or domiciliary care. Dental care or treatment, including appliances and dental implants, except as otherwise stated in this Contract. Care or treatment by means of dose intensive chemotherapy, except as otherwise stated in this Contract. Services or supplies, the primary purpose of which is educational providing the [Member] with any of the following: training in the activities of daily living; instruction in scholastic skills such as reading and writing; preparation for an occupation; or treatment for learning disabilities except as otherwise stated in this Contract. Experimental or Investigational treatments, procedures, hospitalizations, drugs, biological products or medical devices, except as otherwise stated in this Contract. Extraction of teeth, except for bony impacted teeth or as otherwise covered under this Contract. Services or supplies for or in connection with:
Note to carriers. Applies to -
