PLAN PAYMENT AND MEMBER LIABILITY FOR COVERED MEDICATIONS Sample Clauses

PLAN PAYMENT AND MEMBER LIABILITY FOR COVERED MEDICATIONS. The Plan’s payment for Covered Medications purchased from a Participating Pharmacy Provider is the Coinsurance percentage as set forth in SECTION SB - SCHEDULE OF BENEFITS of this Agreement. Any remaining Coinsurance amount is the Member’s responsibility subject to the minimum and maximum Coinsurance amounts set forth in SECTION SB - SCHEDULE OF BENEFITS of this Agreement. Preventive Medications are exempt from any Deductible, Copayment and/or Coinsurance obligation. No benefits are payable for Covered Medications purchased from a Pharmacy Provider that is not a Network Provider. Coverage is not provided for Prescription Drugs and Over-the-Counter Drugs not appearing on the Formulary, unless an exception has been granted pursuant to the prescription drug exceptions process described in this Agreement.
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PLAN PAYMENT AND MEMBER LIABILITY FOR COVERED MEDICATIONS. The Plan’s payment for Covered Medications purchased from a Participating Pharmacy Provider is determined by first subtracting any Deductible liability from the Provider’s Allowable Price. The Coinsurance percentage as set forth in SECTION SB - SCHEDULE OF BENEFITS of this Agreement is then applied to that amount once the Deductible, if any, has been satisfied. Any remaining Coinsurance amount is the Member’s responsibility. The Member’s total liability for Covered Medications is the sum of any Deductible and Coinsurance obligations, if any. However, until the Member has satisfied their Deductible, the Participating Pharmacy Provider is entitled to collect from the Member 100% of the Provider’s Allowable Price for the Covered Medication at the time of purchase. Preventive Medications are exempt from any Deductible and/or Coinsurance obligation. No benefits are payable for Covered Medications purchased from a Pharmacy Provider that is not a Network Provider. Coverage is not provided for Prescription Drugs and Over-the-Counter Drugs not appearing on the Formulary, unless an exception has been granted pursuant to the prescription drug exceptions process described in the SECTION XX - XXXXX CARE MANAGEMENT SERVICES of this Agreement.
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PLAN PAYMENT AND MEMBER LIABILITY FOR COVERED MEDICATIONS. The Plan’s payment for Covered Medications purchased from a Participating Pharmacy Provider is the Coinsurance percentage of the Provider’s Allowable Price as set forth in SECTION SB - SCHEDULE OF BENEFITS of this Agreement. Any remaining Coinsurance amount is the Member’s responsibilitysubject to the minimum and maximum coinsurqnce amount set forth in the OUTPATIENT PRESCRIPTION DRUGS Paragraph in the COVERED SERVICES Subsection of SECTION SB - SCHEDULE OF BENEFITS of this Agreement. Preventive Medications are exempt from any Deductible, Copayment and/or Coinsurance obligation. No benefits are payable for Covered Medications purchased from an Out-of-Network Provider.
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Related to PLAN PAYMENT AND MEMBER LIABILITY FOR COVERED MEDICATIONS

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  • Workers’ Compensation and Employer’s Liability (i) Workers’ Compensation insurance indicating compliance with any applicable labor codes, acts, Laws or statutes, state or federal, where Seller performs Work. (ii) Employers’ Liability insurance shall not be less than one million dollars ($1,000,000.00) for injury or death occurring as a result of each accident.

  • Compensation and Billing 6.1 The Facility shall only seek payment from EGID for the provision of Covered Services. The Facility agrees to accept the amount of the Allowable Fee for Covered Services as payment in full and agrees to only request payment from the Member for deductible, co-insurance and amounts for defined Non-Covered Services attributable to the Member’s Health Choice Plan. The payment shall be calculated and limited to the methodologies defined by this Contract. 6.2 When the Allowable Fee exceeds billed charges, EGID shall pay the appropriate percentage of the Allowable Fee and Member shall pay the appropriate percentage of billed charges unless the Member has met the stop loss limitation and then EGID shall pay the Allowable Fee and the Member has no liability. 6.3 When processing inpatient claims, EGID shall determine the MS-DRG Allowable Fee for non- transfer cases according to the following formula: Skilled Nursing Facility Services, Day Treatment and Residential treatment will be reimbursed utilizing the per diem methodology. In no event shall a per diem qualify as an Outlier. These benefits shall be allowed when the Member has received Medically Necessary Covered Services subject to the following policy limitations and conditions: a) EGID shall pay the appropriate percentage of the MS-DRG Allowable Fee and the Member shall pay the remainder of the MS-DRG Allowable Fee unless the Member has met the stop loss limitation, and then EGID shall pay one hundred percent (100%) of the MS-DRG Allowable Fee and the Member has no liability.‌ b) The MS-DRG shall be controlling, subject to EGID’s approval and Article X of the Contract.‌ c) The MS-DRG Allowable Fee does not include any physician professional component fees, which are considered for payment according to separately billed Current Procedural Terminology code Allowable Fees.‌ d) EGID may reduce its payment by any deductibles, coinsurance and co- payments owed by the Member.‌ e) EGID shall include the day of admission but not the day of discharge when computing the‌ number of facility days provided to a Member. Observation Facility confinements for which a room and board charge is incurred shall be paid based on inpatient benefits.‌ f) In the case of a transfer, the Transfer Allowable Fee for the transferring Facility shall be calculated as follows:‌ Transfer Allowable Fee = (MS-DRG Allowable Fee/Geometric Mean Length of Stay) x (Length of Stay + 1 day) The total Transfer Allowable Fee paid to the transferring Facility shall be capped at the amount of the MS-DRG Allowable Fee for a non-transfer case. EGID shall allow payment to the receiving Facility, if it is also the final discharging Facility, at the MS- DRG Allowable Fee as if it were an original admission.‌ g) EGID shall use the current version of the CMS MS-DRG grouper to categorize what shall constitute a procedure. XXXX’s and the Member’s financial liability shall be limited to the Allowable Fee as determined by XXXX.‌‌ h) The Facility agrees not to charge more for Medical Services to Members than the amount normally charged by the Facility to other patients for similar services.‌ i) For Outlier cases, EGID shall base its payment to the Facility using an Outlier Allowable Fee plus the MS-DRG Allowable Fee. The following formula shall be utilized to calculate the Outlier Allowable Fee:‌ Outlier Allowable Fee = [Billed Charges – (MS-DRG Allowable Fee + Outlier Threshold)] x Marginal Cost Factor 6.4 When processing Outpatient claims, XXXX agrees to pay the Facility the Allowable Fee based on appropriate billing according to the following: a) If a procedure does not have an Allowable Fee, EGID will allow a percentage of the billed charges for Covered Services.‌ b) EGID shall pay the appropriate percentage of the Allowable Fee and the Member shall pay the remainder based on the Member’s plan of benefits unless the Member has met the stop loss limitation, and then EGID shall pay 100% of the Allowable Fee and the Member has no liability.‌‌‌

  • Compensation and Employee Benefits SECTION 13.01.

  • Reporting Total Compensation of Recipient Executives 1. Applicability and what to report. You must report total compensation for each of your five most highly compensated executives for the preceding completed fiscal year, if— i. the total Federal funding authorized to date under this award is $25,000 or more; ii. in the preceding fiscal year, you received— (a) 80 percent or more of your annual gross revenues from Federal procurement contracts (and subcontracts) and Federal financial assistance subject to the Transparency Act, as defined at 2 CFR 170.320 (and subawards); and (b) $25,000,000 or more in annual gross revenues from Federal procurement contracts (and subcontracts) and Federal financial assistance subject to the Transparency Act, as defined at 2 CFR 170.320 (and subawards); and iii. The public does not have access to information about the compensation of the executives through periodic reports filed under section 13(a) or 15(d) of the Securities Exchange Act of 1934 (15 U.S.C. 78m(a), 78o(d)) or section 6104 of the Internal Revenue Code of 1986. (To determine if the public has access to the compensation information, see the U.S. Security and Exchange Commission total compensation filings at xxxx://xxx.xxx.xxx/answers/execomp.htm.) 2. Where and when to report. You must report executive total compensation described in paragraph A.1. of this award term: i. As part of your registration profile at xxxxx://xxx.xxx.gov. ii. By the end of the month following the month in which this award is made, and annually thereafter.

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