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

$1,900 Annual In-Network Out-of-Pocket Maximum
» Up-to $5,700 for a family of 3 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

$10 Co-Pay for Generics
$45 Co-Pay for Brand Names
» Co-Pay is per 30-day Supply
» If Less than Co-Pay Only Pay Full Cost
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Mail Order Pharmacy Co-Pays

$20 Co-Pay for Generics
$90 Co-Pay for Brand Names
» Co-Pay is per 90-day Supply
» If Less than Co-Pay Only Pay Full Cost
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Specialty Pharmacy Co-Pays

$ 10 Co-Pay for Generics
$ 60 Co-Pay for Preferred Brand Names
$100 Co-Pay for Non-Preferred Brand Names
» Co-Pay is Per 30-day Supply
» If Less than Co-Pay Only Pay Full Cost
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Enhancements

$ 0 Co-Pay for Generic Diabetic Medications
» Includes: Insulin, Meters, Strips, Syringes, and Oral Meds

$ 0 Co-Pay for Brand Name Diabetic Supplies
» Includes: Meters, Strips and Syringes

$10 Co-Pay for Brand Name Diabetic Medications
» Includes: Insulin and Oral Meds

$ 0 Co-Pay for Generic ACE Inhibitors
» For the treatment of High Blood Pressure

$ 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.
» 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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