Retail Covered Medications Sample Clauses

Retail Covered Medications. Tier 1 85% Provider’s Allowable Price Not subject to Deductible However, the Member’s minimum and maximum Coinsurance obligation for up to a 90 day supply at retail shall be indexed as follows: For each separate prescription order or refill for up to a 31 day supply, the Member’s minimum Coinsurance obligation is $3 or the cost of the Covered Medication, whichever is lower, and the Member’s maximum Coinsurance obligation is $10 For each separate prescription order or refill for between 32 days and 60 days supply, the Member’s minimum Coinsurance obligation is $6 or the cost of the Covered Medication, whichever is lower, and the Member’s maximum Coinsurance obligation is $20. For each separate prescription order or refill for between 61 days and 90 days supply, the Member’s minimum Coinsurance obligation is $9 or the cost of the Covered Medication, whichever is lower, and the Member’s maximum Coinsurance obligation is $30.
Sample 1Sample 2
AutoNDA by SimpleDocs
Retail Covered Medications. (Closed Formulary) 100% provider’s Not Covered allowable price Generic Drugs and $10 copayment or Not Covered Over-the-Counter Drugs a copayment equal to the provider’s allowable price per prescription order or refill, whichever is less. Brand Drugs $20 copayment or a Not Covered copayment equal to the provider’s allowable price per prescription order or refill, whichever is less. Mail Order Maintenance 100% provider’s Not Covered Covered Medications allowable price (Closed Formulary) Generic Drugs and $20 copayment or a Not Covered Over the Counter Drugs copayment equal to the provider’s allowable price for each 90-day supply, whichever is less. Brand Drugs $40 copayment or a Not Covered copayment equal to the provider’s allowable price for each 90-day supply, whichever is less. COVERED SERVICES O. PREVENTIVE SERVICES NETWORK SERVICES OUT-OF-NETWORK SERVICES Pediatric Care 90% PRC 70% PRC Pediatric Immunizations 90% PRC Not Covered (Pediatric immunization benefits are exempt from all deductibles or dollar limits.) Routine Physical Examinations 90% PRC Not Covered Routine Gynecological Examination and Pap Test 90% PRC Not Covered (Routine gynecological examinations and papanicolaou smear benefits are exempt from all deductibles or maximums.) Allergy Extract/Injections 90% PRC 70% PRC Adult Immunizations and Therapeutic Injections 90% PRC Not Covered Mammographic Screening 90% PRC Not Covered P. PRIVATE DUTY NURSING 90% PRC 70% PRC SERVICES Q. PROSTHETIC APPLIANCES 90% PRC 70% PRC R. SKILLED NURSING FACILITY SERVICES 90% PRC 70% PRC Limited to 100 days per benefit period, and up to 50 days may be used out-of-network.
Sample 1
Retail Covered Medications. Tier 1 85% of the Provider’s Allowable Price Not Covered Not Subject to Deductible However, the Member’s minimum and maximum Coinsurance obligation for up to a 90 day supply at retail shall be indexed as follows: For each separate prescription order or refill for up to a 31 day supply, the Member’s minimum Coinsurance obligation is $3 or the cost of the Covered Medication, whichever is lower, and the Member’s maximum Coinsurance obligation is $10. Not Covered For each separate prescription order or refill for between 32 days and 60-days supply, the Member’s minimum Coinsurance obligation is $6 or the cost of the Covered Medication, whichever is lower, and the Member’s maximum Coinsurance obligation is $20. Not Covered For each separate prescription order or refill for between 61 days and 90 days supply, the Member’s minimum Coinsurance obligation is $9 or the cost of the Covered Medication, whichever is lower, and the Member’s maximum Coinsurance obligation is $30. Not Covered Tier 2 75% Provider’s Allowable Price Not Covered Not Subject to Deductible However, the Member’s minimum and maximum Coinsurance obligation for up to a 90 day supply at retail shall be indexed as follows: For each separate prescription order or refill for up to a 31 day supply, the Member’s minimum Coinsurance obligation is $20 or the cost of the Covered Medication, whichever is lower, and the Member’s maximum Coinsurance obligation is $75. Not Covered For each separate prescription order or refill for between 32 days and 60-days supply, the Member’s minimum Coinsurance obligation is $40 or the cost of the Covered Medication, whichever is lower, and the Member’s maximum Coinsurance obligation is $150. Not Covered For each separate prescription order or refill for between 61 days and 90 days supply, the Member’s minimum Coinsurance obligation is $60 or the cost of the Covered Medication, whichever is lower, and the Member’s maximum Coinsurance obligation is $225. Not Covered Tier 3 65% Provider’s Allowable Price Not Covered Not Subject to Deductible However, the Member’s minimum and maximum Coinsurance obligation for up to a 90 day supply at retail shall be indexed as follows: For each separate prescription order or refill for up to a 31 day supply, the Member’s minimum Coinsurance obligation is $70 or the cost of the Covered Medication, whichever is lower, and the Member’s maximum Coinsurance obligation is $250. Not Covered For each separate prescription order or refill for between ...
Sample 1
Retail Covered Medications. (Closed Formulary) 100% provider’s Not Covered allowable price Generic Drugs and $10 copayment or Not Covered Over-the-Counter Drugs a copayment equal to the provider’s allowable price per prescription order or refill, whichever is less. Brand Drugs $20 copayment or a Not Covered copayment equal to the provider’s allowable price per prescription order or refill, whichever is less. Mail Order Maintenance 100% provider’s Not Covered Covered Medications allowable price (Closed Formulary) Generic Drugs and $20 copayment or a Not Covered
Sample 1
Retail Covered Medications. Tier 1 85% of the Provider’s Allowable Price Not Covered Not Subject to Deductible However, the Member’s minimum and maximum Coinsurance obligation for up to a 90 day supply at retail shall be indexed as follows: For each separate prescription order or refill for up to a 31 day supply, the Member’s minimum Coinsurance obligation is $3 or the cost of the Covered Medication, whichever is lower, and the Member’s maximum Coinsurance obligation is $10. Not Covered
Sample 1
Retail Covered Medications a) Generic Drugs and 80% of the Provider’s Allowable Price per Over-the-Counter Drugs prescription order or refill. The subscriber’s coinsurance liability will never be less than $10 or more than $100.
Sample 1

Related to Retail Covered Medications

  • LIMITATIONS OF COVERED MEDICAL SERVICES In order to be covered, the Member’s Attending Physician must specifically prescribe such services and such services must be consequent to treatment of the cleft lip or cleft palate.

  • Durable Medical Equipment (DME), Medical Supplies Prosthetic Devices, Enteral Formula or Food, and Hair Prosthesis (Wigs) • Items typically found in the home that do not need a prescription and are easily obtainable such as, but not limited to: o adhesive bandages; o elastic bandages; o gauze pads; and o alcohol swabs. • DME and medical supplies prescribed primarily for the convenience of the member or the member’s family, including but not limited to, duplicate DME or medical supplies for use in multiple locations or any DME or medical supplies used primarily to assist a caregiver. • Non-wearable automatic external defibrillators. • Replacement of durable medical equipment and prosthetic devices prescribed because of a desire for new equipment or new technology. • Equipment that does not meet the basic functional need of the average person. • DME that does not directly improve the function of the member. • Medical supplies provided during an office visit. • Pillows or batteries, except when used for the operation of a covered prosthetic device, or items for which the sole function is to improve the quality of life or mental wellbeing. • Repair or replacement of DME when the equipment is under warranty, covered by the manufacturer, or during the rental period. • Infant formula, nutritional supplements and food, or food products, whether or not prescribed, unless required by R.I. Law §27-20-56 for Enteral Nutrition Products, or delivered through a feeding tube as the sole source of nutrition. • Corrective or orthopedic shoes and orthotic devices used in connection with footwear, unless for the treatment of diabetes. Experimental or Investigational Services • Treatments, procedures, facilities, equipment, drugs, devices, supplies, or services that are experimental or investigational except as described in Section 3. Gender Reassignment Services • Reversal of gender reassignment surgery.

  • Product Coverage This Agreement shall apply to all manufactured products, - including capital goods, processed agricultural products, and those products failing outside the definition of agricultural products as set out in this Agreement. Agricultural products shall be excluded from the CEPT Scheme.

  • Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and Hair Prosthesis (Wigs) This plan covers durable medical equipment and supplies, prosthetic devices and enteral formula or food as described in this section. Durable Medical Equipment (DME) DME is equipment which: • can withstand repeated use; • is primarily and customarily used to serve a medical purpose; • is not useful to a person in the absence of an illness or injury; and • is for use in the home. DME includes supplies necessary for the effective use of the equipment. This plan covers the following DME: • wheelchairs, hospital beds, and other DME items used only for medical treatment; and • replacement of purchased equipment which is needed due to a change in your medical condition or if the device is not functional, no longer under warranty, or cannot be repaired. DME may be classified as a rental item or a purchased item. In most cases, this plan only pays for a rental DME up to our allowance for a purchased DME. Repairs and supplies for rental DME are included in the rental allowance. Preauthorization may be required for certain DME and replacement or repairs of DME. Medical Supplies Medical supplies are consumable supplies that are disposable and not intended for re- use. Medical supplies require an order by a physician and must be essential for the care or treatment of an illness, injury, or congenital defect. Covered medical supplies include: • essential accessories such as hoses, tubes and mouthpieces for use with medically necessary DME (these accessories are included as part of the rental allowance for rented DME); • catheters, colostomy and ileostomy supplies, irrigation trays and surgical dressings; and • respiratory therapy equipment. Diabetic Equipment and Supplies This plan covers diabetic equipment and supplies for the treatment of diabetes in accordance with R.I. General Law §27-20-30. Covered diabetic equipment and supplies include: • therapeutic or molded shoes and inserts for custom-molded shoes for the prevention of amputation; • blood glucose monitors including those with special features for the legally blind, external insulin infusion pumps and accessories, insulin infusion devices and injection aids; and • lancets and test strips for glucose monitors including those with special features for the legally blind, and infusion sets for external insulin pumps. The amount you pay differs based on whether the equipment and supplies are bought from a durable medical equipment provider or from a pharmacy. See the Summary of Pharmacy Benefits and the Summary of Medical Benefits for details. Coverage for some diabetic equipment and supplies may only be available from either a DME provider or from a pharmacy. Visit our website to determine if this is applicable or call our Customer Service Department. Prosthetic Devices Prosthetic devices replace or substitute all or part of an internal body part, including contiguous tissue, or replace all or part of the function of a permanently inoperative or malfunctioning body part and alleviate functional loss or impairment due to an illness, injury or congenital defect. Prosthetic devices do not include dental prosthetics. This plan covers the following prosthetic devices as required under R.I. General Law § 27-20-52: • prosthetic appliances such as artificial limbs, breasts, larynxes and eyes; • replacement or adjustment of prosthetic appliances if there is a change in your medical condition or if the device is not functional, no longer under warranty and cannot be repaired; • devices, accessories, batteries and supplies necessary for prosthetic devices; • orthopedic braces except corrective shoes and orthotic devices used in connection with footwear; and • breast prosthesis following a mastectomy, in accordance with the Women’s Health and Cancer Rights Act of 1998 and R.I. General Law 27-20-29. The prosthetic device must be ordered or provided by a physician, or by a provider under the direction of a physician. When you are prescribed a prosthetic device as an inpatient and it is billed by a provider other than the hospital where you are an inpatient, the outpatient benefit limit will apply. Enteral Formulas or Food (Enteral Nutrition) Enteral formula or food is nutrition that is absorbed through the intestinal tract, whether delivered through a feeding tube or taken orally. Enteral nutrition is covered when it is the sole source of nutrition and prescribed by the physician for home use. In accordance with R.I. General Law §27-20-56, this plan covers enteral formula taken orally for the treatment of: • malabsorption caused by Crohn’s Disease; • ulcerative colitis; • gastroesophageal reflux; • chronic intestinal pseudo obstruction; and • inherited diseases of amino acids and organic acids. Food products modified to be low protein are covered for the treatment of inherited diseases of amino acids and organic acids. Preauthorization may be required. The amount that you pay may differ depending on whether the nutrition is delivered through a feeding tube or taken orally. When enteral formula is delivered through a feeding tube, associated supplies are also covered. Hair Prosthesis (Wigs) This plan covers hair prosthetics (wigs) worn for hair loss suffered as a result of cancer treatment in accordance with R.I. General Law § 27-20-54 and subject to the benefit limit and copayment listed in the Summary of Medical Benefits. This plan will reimburse the lesser of the provider’s charge or the benefit limit shown in the Summary of Medical Benefits. If the provider’s charge is more than the benefit limit, you are responsible for paying any difference. Early Intervention Services (EIS) This plan covers Early Intervention Services in accordance with R.I. General Law §27- 20-50. Early Intervention Services are educational, developmental, health, and social services provided to children from birth to thirty-six (36) months. The child must be certified by the Rhode Island Department of Human Services (DHS) to enroll in an approved Early Intervention Services program. Services must be provided by a licensed Early Intervention provider and rendered to a Rhode Island resident. Members not living in Rhode Island may seek services from the state in which they reside; however, those services are not covered under this plan. Early Intervention Services as defined by DHS include but are not limited to the following: • speech and language therapy; • physical and occupational therapy; • evaluation; • case management; • nutrition; • service plan development and review; • nursing services; and • assistive technology services and devices.

  • Other Products and Services As our customer, you have access to a suite of financial products and services availed by ourselves, our affiliates and strategic partners designed to help you address and achieve your financial needs and goals. You agree that you can obtain information about such Products and Services via our website xxx.xxxxxxxx.xxx.xx and you further agree that we can from time to time communicate information in relation to such Products or Services to you specifically or generally to all cardmembers via such communication mode as we consider appropriate.

  • Products and Services General Information The Vendor Agreement (“Agreement”) made and entered into by and between The Interlocal Purchasing System (hereinafter “TIPS”) a government cooperative purchasing program authorized by the Region 8 Education Service Center, having its principal place of business at 0000 XX Xxx 000 Xxxxx, Xxxxxxxxx, Xxxxx 00000 and the TIPS Vendor. This Agreement consists of the provisions set forth below, including provisions of all attachments referenced herein. In the event of a conflict between the provisions set forth below and those contained in any attachment, the provisions set forth shall control unless otherwise agreed by the parties in writing and by signature and date on the attachment. A Purchase Order (“PO”), Agreement or Contract is the TIPS Member’s approval providing the authority to proceed with the negotiated delivery order under the Agreement. Special terms and conditions as agreed between the Vendor and TIPS Member should be added as addendums to the Purchase Order, Agreement or Contract. Items such as certificate of insurance, bonding requirements, small or disadvantaged business goals are some, but not all, of the possible addendums.

  • Required Procurement Procedures for Obtaining Goods and Services The Grantee shall provide maximum open competition when procuring goods and services related to the grant-assisted project in accordance with Section 287.057, Florida Statutes.

  • Third Party Products and Services Through its Product(s), Palo Alto Networks may make available to you third-party products or services (“third-party apps”) which contain features designed to interoperate with our Products. To use such features, you must either obtain access to such third-party apps from their respective providers or permit Palo Alto Networks to obtain access on your behalf. All third-party apps are optional and if you choose to utilize such third-party apps:

  • Additional Products and Services Subject to the allocation of funds, the CPO may add similar equipment, supplies, services, or locations, within the scope of this Agreement, to the list of equipment, supplies, services, or locations to be performed or provided by giving written notification to Contractor. For purposes of this Section, the “Effective Date” means the date specified in the notification from the CPO. As of the Effective Date, each item added is subject to this Agreement, as if it had originally been a part, but the charge for each item starts to accrue only on the Effective Date. In the event the additional equipment, supplies, services, or locations are not identical to the items(s) already under this Agreement, the charges therefor will then be Contractor’s normal and customary charges or rates for the equipment, supplies, services, or locations classified in the Fees and Costs (Exhibit “F”).

  • Durable Medical Equipment (DME a. Coverage includes purchase or rental, when Medically Necessary, of such DME that:

Draft better contracts in just 5 minutes Get the weekly Law Insider newsletter packed with expert videos, webinars, ebooks, and more!