any expense in excess of: (i) the drug limited fee schedule for drugs dispensed by non-participating pharmacies; or (ii) the prescription drug negotiated rate for drugs dispensed by participating pharmacies or by the mail service program. Prescription Drug Negotiated Rate is the rate that the cl...
and cost effectiveness of case management activities. Facilitates application process for accessing local, state, and federally funded programs (e. g. , Medicaid, Medicare, and Disability) and/or refers to appropriate community agencies in cases of suspected patient abuse/neglect when identified. Pr ...
For some claims (like those from hospitals and outpatient centers) we may use other information and data sources to determine the charge. And some of our plans pay based on a different kind of fee schedule. Also, for some non-participating providers we may pay based on other contractual ...