Mail Order Program Clause Samples
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Mail Order Program. If You elect to use the mail- order service, You must mail Your Prescription Order to the address provided on the mail- order prescription form and send in Your payment for each prescription filled or refilled. Each prescription or refill is subject to the Copayment shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS and any applicable pricing differences, payable by Member directly to the mail- order Pharmacy. Some drugs may not be available through the mail- order program. If You have any questions about this mail- order program, need assistance in determining the amount of Your payment, or need to obtain the mail- order prescription claim form, You may access the website at ▇▇▇.▇▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇ or contact customer service at the toll- free number on Your identification card. Mail the completed form, Your Prescription Order(s) and payment to the address indicated on the form. Prescription Drugs Purchased Outside of the Service Area. HMO will reimburse You for the Allowable Amount of the prescription drugs less the Out- of- Area Drug Copayment shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS, for covered prescription drugs which You purchase outside of the Service Area. You must submit a completed claim form to HMO, including Your name, the prescribing authorized Health Care Practitioner’s name, the date of purchase, NDC of the drug, and itemized receipts indicating the total cost of the prescription within ninety (90) days of the date of purchase to qualify for reimbursement under the PHARMACY BENEFITS. You may access the website at ▇▇▇.▇▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇ to obtain a prescription drug claim form.
Mail Order Program. Except as provided in Section 11.4, all Members have the option of ordering Covered Prescription Drugs via mail order. A Member may obtain up to a twelve (12) month supply of contraceptives at one time. SAMPLE
Mail Order Program. If You elect to use the mail-order service, You must mail Your Prescription Order to the address provided on the mail-order prescription form and send in Your payment for each prescription filled or refilled. Each prescription or refill is subject to the Copayment shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS and any applicable pricing differences, payable by Member directly to the mail order Pharmacy. Some drugs may not be available through the mail-order program. If You have any questions about this mail-order program, need assistance in determining the amount of Your payment, or need to obtain the mail-order prescription claim form, access the website at ▇▇▇.▇▇▇▇▇▇.▇▇▇ or contact customer service at the toll-free number on Your identification card. Mail the completed form, Your Prescription Order(s) and payment to the address indicated on the form. The HMO Specialty Pharmacy Program delivery service offers: • coordination of coverage between You, Your Health Care Practitioner and HMO; • educational materials about the patient’s particular condition and information about managing potential medication side effects; • syringes, sharps containers, alcohol swabs and other supplies with every shipment for FDA approved self- injectable medications; and • access to a pharmacist for urgent medication issues 24 hours a day, 7 days a week, 365 days each year. The Drug List which includes these Specialty Drugs is available by accessing the website at ▇▇▇.▇▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇/▇▇▇▇▇▇▇▇▇▇▇▇-▇▇▇▇-▇▇▇▇-▇▇▇▇▇▇▇▇▇▇▇/▇▇▇▇-▇▇▇▇▇ or by contacting customer service at the toll-free number on Your identification card. Your cost will be the applicable Copayment shown in the Schedule of Copayments and Benefit Limits as well as any applicable pricing differences. Prescription Drugs Purchased Outside of the Service Area. HMO will reimburse You for the Allowable Amount of the prescription drugs less the Out-of-Area Drug Copayment shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS, for covered prescription drugs which You purchase outside of the Service Area. You must submit a completed claim form to HMO, within ninety (90) days of the date of purchase to qualify for reimbursement under the PHARMACY BENEFITS. You may access the website at ▇▇▇.▇▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇/▇▇▇▇▇/▇▇▇▇▇▇▇▇▇▇ to obtain a prescription drug claim form.
Mail Order Program. All Members have the option of ordering Prescription Drugs via mail order. Members ordering Prescription Drugs through the mail order program will be entitled to a thirty- four (34) day supply for non-Maintenance Drugs and a ninety (90) day supply for Maintenance Drugs.
Mail Order Program. Co-pay per prescription—90 Day Supply Generic $10.00 Formulary Brand $20.00 Non- Formulary Brand $50.00 A. A1 Account Clerk
Mail Order Program. Co-pay per prescription—90 Day Supply
Mail Order Program. Members may purchase refills for self-administered maintenance drugs covered under sections F-1(b)(i), F-1(b)(ii), F-1(c), and F-1(e) for a 90-consecutive-day supply by mail order to the Members home upon payment of an amount that member would pay for a 60-consecutive-day supply.