forth in the Contract. In addition, the Member may appeal a denial to the Independent Health Care Appeals Program.] [The Contract only pays benefits for Prescription Drugs which are: a) prescribed by a Practitioner (except for insulin) b) dispensed by a Participating Pharmacy [or by a Participating Mail Order Pharmacy]; and c) needed to treat an Illness or Injury covered under this Contract. Such charges will not include charges made for more than: a) [a 90-day supply for each prescription or refill[ which is not obtained through the Mail Order Program] where the copayment is calculated based on the multiple of 30-day supplies received;] b) [a 90-day supply of a Maintenance Drug obtained through the Mail Order Program where the copayment is the copayment specified for a 90-day supply;] and c) the amount usually prescribed by the Member's Practitioner. A charge will be considered to be incurred at the time the Prescription Drug is received.] [[We will arrange for audits that will take place at a time mutually agreeable to the Participating Pharmacy [and the Participating Mail Order Pharmacy] or the pharmacist and the auditor. The audits shall only include the review of documents relating to persons and prescription plans reimbursable by Us.] [Note to carriers: If a carrier elects to include audit procedures in the policy, include your specific audit procedures as an additional paragraph.] [We will not restrict or prohibit, directly or indirectly, a Participating Pharmacy [or a Participating Mail Order Pharmacy] from charging the Member for charges that are in addition to charges for the Prescription Drug, for dispensing the Prescription Drug or for prescription counseling provided such other charges have been approved by the New Jersey Board of Pharmacy, and the amount of the charges for the additional services and the purchaser's out-of-pocket cost for those services has been disclosed to the Member prior to dispensing the drug.] [Note to carriers: Carriers may include information regarding the pharmacy benefit manager, quantity and supply limit rules, appeals procedures and policies regarding refills and vacation overrides.]
forth in the Contract. In addition, the Member may appeal a denial to the Independent Health Care Appeals Program.] [The Contract only pays benefits for Prescription Drugs which are: a) prescribed by a Practitioner (except for insulin) b) dispensed by a Participating Pharmacy [or by a Participating Mail Order Pharmacy]; and c) needed to treat an Illness or Injury covered under this Contract. Such charges will not include charges made for more than: a) [a 90-day supply for each prescription or refill[ which is not obtained through the Mail Order Program] where the copayment is calculated based on the multiple of 30-day supplies received;] b) [a 90-day supply of a Maintenance Drug obtained through the Mail Order Program where the copayment is the copayment specified for a 90-day supply;] and c) the amount usually prescribed by the Member's Practitioner. A charge will be considered to be incurred at the time the Prescription Drug is received.] [[We will arrange for audits that will take place at a time mutually agreeable to the Participating Pharmacy [and the Participating Mail Order Pharmacy] or the pharmacist and the auditor. The audits shall only include the review of documents relating to persons and prescription plans reimbursable by Us.] [Note to carriers: If a carrier elects to include audit procedures in the policy, include your specific audit procedures as an additional paragraph.] [We will not restrict or prohibit, directly or indirectly, a Participating Pharmacy [or a Participating Mail Order Pharmacy] from charging the Member for charges that are in addition to charges for the Prescription Drug, for dispensing the Prescription Drug or for prescription counseling provided such other charges have been approved by the New Jersey Board of Pharmacy, and the amount of the charges for the additional services and the purchaser's out-of-pocket cost for those services has been disclosed to the Member prior to dispensing the drug.] [Note to carriers: Carriers may include information regarding the pharmacy benefit manager, quantity and supply limit rules, appeals procedures and policies regarding refills and vacation overrides.]
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