Common use of Five-Tier Copayment Structure Clause in Contracts

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. 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. 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 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. 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. 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. In accordance with RIGL § 27-18.94, this plan covers one two-pack epinephrine auto- injector kit, with no copayment after deductible, per plan year, as indicated on our formulary. Please contact our Customer Service Department for details.

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.. I-COC-3-2023-BX/I-SOB-15-2023-BX 7 BlueSolutions for HSA Direct

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.. 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. SG-COC-2-2024-BX & SG-SOB-17-2024-BX 8 BlueSolutions for

Five-Tier Copayment Structure. This prescription drug plan formulary has a five-tiered 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.. 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. SG-COC-2-2023-BX & SG-SOB-16-2023-BX 8 BlueSolutions for HSA

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.. In accordance with RIGL § 27-18.94, this plan covers one two-pack epinephrine auto- injector kit, with no copayment after deductible, per plan year, as indicated on our formulary. Please contact our Customer Service Department for details. I-COC-3-2025-BX/I-SOB-14-2025-BX 9 BlueSolutions for

Five-Tier Copayment Structure. This prescription drug plan formulary has a five-tiered 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.. 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. SG-COC-2-2023-BX & SG-SOB-14-2023-BX 8 BlueSolutions for HSA