Prescription Coverage

Quick Links:
» Resources
» Overview
» Retail Pharmacy Co-Pays
» Mail Order Pharmacy Co-Pays
» Specialty Pharmacy Co-Pays
» Enhancements
» Pharmacy Management Controls

Resources

» Provider Search: Click Here
» Video: Watch
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Overview

$2,000 Annual In-Network Out-of-Pocket Maximum
» Up-to $4,000 for a family of 2 or more
No Formulary
No Generic Mandate
No Deductible for Generics
$50 Deductible for Brand Name's
» Per covered individual, not per Brand Name Script
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Retail Pharmacy Co-Pays

30        90          Days Supply
$10    $25    Generics
$45    $112    Brand Names

» If less than Co-Pay, only pay full cost
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Mail Order Pharmacy Co-Pays

90          Days Supply
$25    Generics
$112    Brand Names

» If less than Co-Pay, only pay full cost
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Specialty Pharmacy Co-Pays

30          Days Supply
$10    Generics
$60    Preferred Brands
$100    Non-Preferred Brands

» If less than Co-Pay, only pay full cost
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Enhancements

$5 Co-Pay for Generic Oral Diabetic Medications

$0 Co-Pay for Over-The-Counter Acid-Reducers
» Such as: Nexium, Prilosec, Prevacid, Zegerid & Omeprazole
» Requires a Prescription

$0 Co-Pay for Oral Contraceptives & Contraceptive Devices
» Requires a Prescription

$5 Co-Pay for Over-The-Counter Anti-Histamines
» Such as: Alavert, Claritin & Zyrtec
» Includes all forms such as liquids, gels & tablets
» Requires a Prescription

$5 Co-Pay for Over-The-Counter Allergy Nasal Sprays
» Such as: Flonase, Nasacort & Rhinocort
» Requires a Prescription

$0 Co-Pay for Smoking Cessation Medications
» Some Exclusions & Limitations Apply
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Pharmacy Management Controls

The Health Plan employs a number of management controls in its pharmacy benefits, designed to protect the Health Plan and its Members. Click on the following to learn more:
» Clinical Prior Authorizations: Click Here
» Quantity or Age Limitations: Click Here
» Exclusions: Click Here
» Specialty: Click Here
» Step Therapies: Click Here
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