Five-Tier Copayment Structure Clause Samples

Five-Tier Copayment Structure. This prescription drug plan formulary has a five-tiered copayment structure. The copayment for a prescription drug will vary by tier. The tier placement of a prescription drug on our formulary is subject to change. For more information about our formulary, and to see the tier placement of a particular prescription drug, visit our website or call our Customer Service Department. Below indicates the tier structure for this plan and the amount that you are responsible to pay. You will be responsible for paying the lowest cost of either your copayment, the retail cost of the drug, or the pharmacy allowance. We reserve the right not to accept manufacturer coupons, discount plan payments or other cost share assistance program payments for prescription drug copayments and/or deductibles. In accordance with RIGL § 27-20.8-3, copayments for insulin prescription drugs will not exceed $40 for each thirty-day supply and are not subject to a deductible. Prescription Drugs, other than Specialty Prescription Drugs, and Diabetic Equipment and Supplies (which includes Glucometers, Test Strips, Lancet and Lancet Devices, Needles and Syringes, and Miscellaneous Supplies, calibration fluid): When purchased at a Retail Pharmacy: For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Prorated copayments for a shorter supply periodmay apply for network pharmacy only. See Prescription Drug section for details. For tiers 1, 2, and 3: Up to a 90-day supply of maintenance and non-maintenance prescription drugs is available at certain network retail pharmacies and a 365-day supply for contraceptive prescription drugs is available at all network pharmacies. A copayment will apply for each 30-day supply. For more information about pharmacies offering this option, visit our website. Tier 1: $10 Not Covered Tier 2: $30 Not Covered Tier 3: $50 Not Covered Tier 4: $75 Not Covered Tier 5: See specialty prescription drug section below. Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply of maintenance and non- maintenance prescription drugs. Tier 1: $25 Not Covered Tier 2: $75 Not Covered Tier 3: $125 Not Covered Tier 4: $225 Not Covered Tier 5: See specialty prescription drug section below. Not Covered

Five-Tier Copayment Structure. This prescription drug plan formulary has a five-tiered copayment structure. The copayment for a prescription drug will vary by tier. The tier placement of a prescription drug on our formulary is subject to change. For more information about our formulary, and to see the tier placement of a particular prescription drug, visit our website or call our Customer Service Department. Below indicates the tier structure for this plan and the amount that you are responsible to pay. You will be responsible for paying the lowest cost of either your copayment, the retail cost of the drug, or the pharmacy allowance. We reserve the right not to accept manufacturer coupons, discount plan payments or other cost share assistance program payments for prescription drug copayments and/or deductibles. If prescription drug manufacturer coupons, discount plan payments or other cost share assistance program payments for prescription drug copayments are accepted they may not be counted towards your deductible (if applicable) or your maximum out-of-pocket expense limit. In accordance with RIGL § 27-20.8-3, copayments for insulin prescription drugs will not exceed $40 for each thirty-day supply and are not subject to a deductible.

Five-Tier Copayment Structure. This prescription drug plan formulary has a five-tiered copayment structure. First Tier: generally includes formulary low cost preferred generic Prescription Drugs, which require the lowest copayment. Second Tier: generally includes other certain formulary low cost preferred generic Prescription Drugs, which require a higher

Five-Tier Copayment Structure. This prescription drug plan formulary has a five-tiered copayment structure. The copayment for a prescription drug will vary by tier. The tier placement of a prescription drug on our formulary is subject to change. For more information about our formulary, and to see the tier placement of a particular prescription drug, visit our website or call our Customer Service Department. Below indicates the tier structure for this plan and the amount that you are responsible to pay. You will be responsible for paying the lowest cost of either your copayment, the retail cost of the drug, or the pharmacy allowance.

Five-Tier Copayment Structure. This prescription drug plan formulary has a five -tiered copayment structure. The copayment for a prescription drug will vary by tier. The tier placement of a prescription drug on our formulary is subject to change. For more information about our formulary, and to see the tier placement of a particular prescription drug, visit our website or call our Customer Service Department. Below indicates the tier structure for this plan and the amount that you are responsible to pay. You will be responsible for paying the lowest cost of either your copayment, the retail cost of the drug, or the pharmacy allowance. We reserve the right not to accept manufacturer coupons, discount plan payments or other cost share assistance program payments for prescription drug copayments and/or deductibles. In accordance with RIGL § 27-20.8-3, copayments for insulin prescription drugs will not exceed $40 for each thirty-day supply and are not subject to a deductible.

Five-Tier Copayment Structure. This prescription drug plan formulary has a five-tiered copayment structure. The copayment for a prescription drug will vary by tier. The tier placement of a prescription drug on our formulary is subject to change. For more information about our formulary, and to see the tier placement of a particular prescription drug, visit our website or call our Customer Service Department. Below indicates the tier structure for this plan and the amount that you are responsible to pay. You will be responsible for paying the lowest cost of either your copayment, the retail cost of the drug, or the pharmacy allowance. We reserve the right not to accept manufacturer coupons, discount plan payments or other cost share assistance program payments for prescription drug copayments and/or deductibles. This plan allows for certain preventive prescriptions drugs to be covered, with a copayment, before meeting your plan year deductible. See the Summary of Pharmacy Benefits for the applicable copayment. For a list of these preventive prescription drugs, please visit our website or call our Customer Service Department.

Five-Tier Copayment Structure. This prescription drug plan formulary has a five-tiered copayment structure. The copayment for a prescription drug will vary by tier. The tier placement of a prescription drug on our formulary is subject to change. For more information about our formulary, and to see the tier placement of a particular prescription drug, visit our website or call our Customer Service Department. Below indicates the tier structure for this plan and the amount that you are responsible to pay. You will be responsible for paying the lowest cost of either your copayment, the retail cost of the drug, or the pharmacy allowance. LG-COC/SOB-4-2020-BX 6 BlueSolutions for HSA 1500/3000

Five-Tier Copayment Structure. This prescription drug plan formulary has a five-tiered copayment structure.

Five-Tier Copayment Structure. This prescription drug plan formulary has a five-tiered copayment structure. The copayment for a prescription drug will vary by tier. For more information about our formulary, and to see the tier placement of a particular prescription drug, visit our website or call our Customer Service Department. Our formulary lists generic, preferred brand name, and non-preferred brand name prescription drugs and specialty prescription drugs covered under this agreement. Visit our web site or call our Customer Service Department to: • obtain a copy of the most current formulary listing; • find out what tier a prescription drug is in; • obtain information concerning Specialty Drugs and Specialty Pharmacies. Below indicates the tier structure and the amount that you are responsible to pay. The tier placement of our formulary is subject to change. You will be responsible for paying the lowest cost of either your copayment, the retail cost of the drug, or the pharmacy allowance. The deductible applies to all services (including prescription drugs); except for services designated as preventive care. The network and non-network deductible and copayments (including prescription drug) apply to the out-of-pocket limit. In accordance with Rhode Island General Law §27-18-50.1, a prorated copayment may be applied for covered prescription drugs, used to treat chronic long-term conditions, when prescribed for less than a (30) thirty day supply and dispensed by a network pharmacy if: • the prescribing physician and pharmacist determine it is in the best interest of the member; and • the member requests or agrees to less than a thirty (30) day supply. In addition, in order to qualify for medication synchronization, the covered prescription drug must: • be a maintenance drug used for the management and treatment of a chronic long- term care condition; • not be a controlled substance; • meet all utilization management requirements specific to the drug; • be of a formulation able to be split over the required shortened supply period; and • not have quantity limits or dose optimization criteria that would be violated when synchronized with other prescription drugs.