Pharmacotherapy Benefit Limitations Sample Clauses

Pharmacotherapy Benefit Limitations. Prescription Drugs/Medications purchased at an In-network Pharmacy Two 90-day courses of treatment per Contract Year Refer to your Summary of Benefits and Coverage and your Formulary for your Cost Sharing amount. PHP provides coverage for telemedicine services to the same extent that this agreement covers the same services when provided in-person or In-network. PHP will not impose originating-site restrictions. Coverage may be extended to out-of-network providers in instances where no in- network provider is accessible, as defined by network adequacy standards. A determination by PHP that services delivered through the use of telemedicine are not covered is subject to review and appeal. This benefit has one or more exclusions as specified in the Exclusions Section. All Organ transplants must be performed at an approved center and require Prior Authorization. Presbyterian provides coverage for organ transplants and associated care and will not: Deny that coverage solely on the basis of a covered person's physical or mental disability; Deny to a covered person with a physical or mental disability eligibility or continued eligibility to enroll or to renew coverage under the terms of the health benefit policy or plan solely for the purpose of avoiding the requirements of this section; Penalize or otherwise reduce or limit the reimbursement or provide monetary or nonmonetary incentives to a health care provider to induce that health care provider not to provide an organ transplant or associated care to a covered person with a physical or mental disability; or Reduce or limit coverage benefits to a covered person with a physical or mental disability for the associated care related to organ transplantation as determined in consultation with the physician and patient. Human Solid Organ transplant benefits are Covered for: Kidney Liver Pancreas Intestine Heart Lung multi-visceral (3 or more abdominal Organs) simultaneous multi-Organ transplants – unless investigational pancreas islet cell infusion Meniscal Allograft Autologous Chondrocyte Implantation – knee only Hematopoietic Transplant Benefits are Covered for: o Bone Marrow Transplant including peripheral blood bone marrow stem cell harvesting and transplantation (stem cell transplant) following high dose chemotherapy. Bone marrow transplants are Covered for the following indications: o multiple myeloma o leukemia o aplastic anemia o lymphoma o severe combined immunodeficiency disease (SCID) o Wiskott Xxxxxxx sy...

Pharmacotherapy Benefit Limitations. Prescription Drugs/Medications purchased at an In-network Pharmacy • Two 90-day courses of treatment per Contract Year Refer to your Summary of Benefits and Coverage and your Formulary for your Cost Sharing amount. PHP provides coverage for telemedicine services to the same extent that this agreement covers the same services when provided in-person. PHP will not impose originating-site restrictions. Coverage maybe extended to out-of-network providers in instances where no in-network provider is accessible, as defined by network adequacy standards.

Pharmacotherapy Benefit Limitations. Prescription Drugs/Medications purchased at an In-network Pharmacy • Two 90-day courses of treatment per Contract Year Refer to your Summary of Benefits and Coverage and your Formulary for your Cost Sharing amount.