Standard Option Prescription
Compound Medications:
Your plan covers multi-ingredient compound medications.
Different co-payments may apply for certain medications.
For brand-name medications.
For medications that are on your plan's preferred drug list.
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 Your co-payment is $100.00
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For medications that are not on your plan's preferred drug list.
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Your co-payment is $200.00
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For generic medications.
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Your co-payment is $10.00
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For brand-name medications when a generic is available.
For medications that are on your plan's preferred drug list.
|
Your co-payment is $100.00
|
If the patient or the doctor requests a brand-name medication when a generic equivalent is available your co-payment will be equal to your generic co-payment plus the difference in price between the brand-name medication and its generic equivalent. This difference in price is only charged for certain medications.
For medications that are not on your plan's preferred drug list:
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Your co-payment is $200.00
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If the patient or the doctor requests a non-preferred, brand-name medication when a generic equivalent is available your co-payment will be equal to your generic co-payment plus the difference in price between the brand-name medication and its generic equivalent. This difference in price is only charged for certain medications.
Deductible
A deductible is the amount you must pay before your plan sponsor begins paying for a portion of your prescription costs.
For an individual, the deductible for preferred prescriptions filled at retail or mail order pharmacies is $500.00 every year. To receive prescription coverage, you must meet your individual deductible.
If applicable to your plan the following applies to your Deductible based on percentage.
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If you order a brand-name medication that has a generic equivalent, the difference in cost between the brand-name medication and generic medication will not apply.
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Medications on the Prescription Drug List may not apply to the Benefit Deductible.
According to your plan design your final Deductible amount will also apply to your out-of-pocket.
For an individual, the deductible for non-preferred prescriptions filled at retail or mail order pharmacies is $750.00 every year. To receive prescription coverage, you must meet your individual deductible.
If applicable to your plan the following applies to your Deductible based on percentage:
|
If you order a brand-name medication that has a generic equivalent, the difference in cost between the brand-name medication and generic medication will not apply.
|
|
If you continue using retail after reaching your Retail Refill Limit for maintenance medications, the total cost of the medication will not apply.
|
Medications on the Prescription Drug List may not apply to the Benefit Deductible.
According to your plan design your final Deductible amount will also apply to your out-of-pocket.
Out-Of-Pocket
Your out-of-pocket expense is the maximum amount you will pay before your plan sponsor reduces your co-payments.
For an individual, the out-of-pocket maximum for preferred prescriptions filled at retail or mail order pharmacies is $5950.00 every year.
If applicable to your plan the following applies to your Out-of-Pocket based on percentage:
|
If you order a brand-name medication that has a generic equivalent, the difference in cost between the brand-name medication and generic medication will not apply.
|
Medications on the Prescription Drug List may not apply to the Benefit Out-of-Pocket.
For an individual, the out-of-pocket maximum for non-preferred prescriptions filled at retail or mail order pharmacies is $7000.00 every year.
If applicable to your plan the following applies to your Out-of-Pocket based on percentage
|
If you order a brand-name medication that has a generic equivalent, the difference in cost between the brand-name medication and generic medication will not apply.
|
|
If you continue using retail after reaching your Retail Refill Limit for maintenance medications, the total cost of the medication will not apply.
|
Medications on the Prescription Drug List may not apply to the Benefit Out-of-Pocket.
This information is intended to serve as a general overview of your plan sponsor's prescription benefit program. Please note that the terms of your prescription benefit are subject to change. Please consult your plan sponsor for complete information.
Lookup your prescription at medco here.
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Extended Option Prescription
Compound Medications:
Your plan covers multi-ingredient compound medications.
Different co-payments may apply for certain medications.
For brand-name medications.
For medications that are on your plan's preferred drug list.
|
Your co-payment is $75.00
|
For medications that are not on your plan's preferred drug list.
|
Your co-payment is $150.00
|
For generic medications.
|
Your co-payment is $10.00
|
For brand-name medications when a generic is available.
For medications that are on your plan's preferred drug list.
|
Your co-payment is $75.00
|
If the patient or the doctor requests a brand-name medication when a generic equivalent is available your co-payment will be equal to your generic co-payment plus the difference in price between the brand-name medication and its generic equivalent. This difference in price is only charged for certain medications.
For medications that are not on your plan's preferred drug list:
|
Your co-payment is $150.00
|
If the patient or the doctor requests a non-preferred, brand-name medication when a generic equivalent is available your co-payment will be equal to your generic co-payment plus the difference in price between the brand-name medication and its generic equivalent. This difference in price is only charged for certain medications.
Deductible
A deductible is the amount you must pay before your plan sponsor begins paying for a portion of your prescription costs.
For an individual, the deductible for preferred prescriptions filled at retail or mail order pharmacies is $250.00 every year. To receive prescription coverage, you must meet your individual deductible.
If applicable to your plan the following applies to your Deductible based on percentage.
|
If you order a brand-name medication that has a generic equivalent, the difference in cost between the brand-name medication and generic medication will not apply.
|
Medications on the Prescription Drug List may not apply to the Benefit Deductible.
According to your plan design your final Deductible amount will also apply to your out-of-pocket.
For an individual, the deductible for non-preferred prescriptions filled at retail or mail order pharmacies is $375.00 every year. To receive prescription coverage, you must meet your individual deductible.
If applicable to your plan the following applies to your Deductible based on percentage:
|
If you order a brand-name medication that has a generic equivalent, the difference in cost between the brand-name medication and generic medication will not apply.
|
|
If you continue using retail after reaching your Retail Refill Limit for maintenance medications, the total cost of the medication will not apply.
|
Medications on the Prescription Drug List may not apply to the Benefit Deductible.
According to your plan design your final Deductible amount will also apply to your out-of-pocket.
Out-Of-Pocket
Your out-of-pocket expense is the maximum amount you will pay before your plan sponsor reduces your co-payments.
For an individual, the out-of-pocket maximum for preferred prescriptions filled at retail or mail order pharmacies is $5950.00 every year.
If applicable to your plan the following applies to your Out-of-Pocket based on percentage:
|
If you order a brand-name medication that has a generic equivalent, the difference in cost between the brand-name medication and generic medication will not apply.
|
Medications on the Prescription Drug List may not apply to the Benefit Out-of-Pocket.
For an individual, the out-of-pocket maximum for non-preferred prescriptions filled at retail or mail order pharmacies is $7000.00 every year.
If applicable to your plan the following applies to your Out-of-Pocket based on percentage
|
If you order a brand-name medication that has a generic equivalent, the difference in cost between the brand-name medication and generic medication will not apply.
|
|
If you continue using retail after reaching your Retail Refill Limit for maintenance medications, the total cost of the medication will not apply.
|
Medications on the Prescription Drug List may not apply to the Benefit Out-of-Pocket.
|
|
HSA Option Prescription
Compound Medications:
Your plan covers multi-ingredient compound medications.
Different co-payments may apply for certain medications.
For brand-name medications.
For medications that are on your plan's preferred drug list.
|
Your co-payment is $75.00
|
For medications that are not on your plan's preferred drug list.
|
Your co-payment is $150.00
|
For generic medications.
|
Your co-payment is $10.00
|
For brand-name medications when a generic is available.
For medications that are on your plan's preferred drug list.
|
Your co-payment is $75.00
|
If the patient or the doctor requests a brand-name medication when a generic equivalent is available your co-payment will be equal to your generic co-payment plus the difference in price between the brand-name medication and its generic equivalent. This difference in price is only charged for certain medications.
For medications that are not on your plan's preferred drug list:
|
Your co-payment is $150.00
|
If the patient or the doctor requests a non-preferred, brand-name medication when a generic equivalent is available your co-payment will be equal to your generic co-payment plus the difference in price between the brand-name medication and its generic equivalent. This difference in price is only charged for certain medications.
Deductible
A deductible is the amount you must pay before your plan sponsor begins paying for a portion of your prescription costs.
For an individual, the deductible for preferred prescriptions filled at retail or mail order pharmacies is $2500.00 every year. To receive prescription coverage, you must meet your individual deductible.
If applicable to your plan the following applies to your Deductible based on percentage.
|
If you order a brand-name medication that has a generic equivalent, the difference in cost between the brand-name medication and generic medication will not apply.
|
Medications on the Prescription Drug List may not apply to the Benefit Deductible.
According to your plan design your final Deductible amount will also apply to your out-of-pocket.
For an individual, the deductible for non-preferred prescriptions filled at retail or mail order pharmacies is $3,000.00 every year. To receive prescription coverage, you must meet your individual deductible.
If applicable to your plan the following applies to your Deductible based on percentage:
|
If you order a brand-name medication that has a generic equivalent, the difference in cost between the brand-name medication and generic medication will not apply.
|
|
If you continue using retail after reaching your Retail Refill Limit for maintenance medications, the total cost of the medication will not apply.
|
Medications on the Prescription Drug List may not apply to the Benefit Deductible.
According to your plan design your final Deductible amount will also apply to your out-of-pocket.
Out-Of-Pocket
Your out-of-pocket expense is the maximum amount you will pay before your plan sponsor reduces your co-payments.
For an individual, the out-of-pocket maximum for preferred prescriptions filled at retail or mail order pharmacies is $5950.00 every year.
If applicable to your plan the following applies to your Out-of-Pocket based on percentage:
|
If you order a brand-name medication that has a generic equivalent, the difference in cost between the brand-name medication and generic medication will not apply.
|
Medications on the Prescription Drug List may not apply to the Benefit Out-of-Pocket.
For an individual, the out-of-pocket maximum for non-preferred prescriptions filled at retail or mail order pharmacies is $7000.00 every year.
If applicable to your plan the following applies to your Out-of-Pocket based on percentage
|
If you order a brand-name medication that has a generic equivalent, the difference in cost between the brand-name medication and generic medication will not apply.
|
|
If you continue using retail after reaching your Retail Refill Limit for maintenance medications, the total cost of the medication will not apply.
|
Medications on the Prescription Drug List may not apply to the Benefit Out-of-Pocket.
This information is intended to serve as a general overview of your plan sponsor's prescription benefit program. Please note that the terms of your prescription benefit are subject to change. Please consult your plan sponsor for complete information.
|
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** This information is intended to serve as a general overview of your plan sponsor's prescription benefit program. Please note that the terms of your prescription benefit are subject to change. Please consult your plan sponsor for complete information.
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