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Prescription Drugs

MEDICAL, MENTAL HEALTH AND CHEMICAL DEPENDENCY
  REGULAR PLAN PPO LOW OPTION PLAN 1
  Network Provider 2 Non-
Network Provider 3
Out of A
(For participants residing outside the PPO service area only) 3 4
Network Provider 2 Non-
Network Provider 3
Participants and covered dependents will automatically be enrolled in the Pharmacy Program if you are enrolled in the PPO Plan only. The benefits are administered by Express Scripts.
Prescription Drugs 26
Retail: (up to a 30-day supply only)
  • Generic
  • Preferred Brand
  • Non-Preferred Brand 29  30
$10 copayA fixed dollar amount you pay for an eligible expense at the time the service is provided. 31
$15 copay 31
$25 copay 31
$10 copay 28
$15 copay 28
$25 copay 28
$10 copay
$15 copay
$25 copay
Not covered 31 Not covered
Mail Order (up to a 90-day supply) 32
  • Generic
  • Preferred Brand
  • Non-Preferred Brand 29,  30
$20 copay 31
$30 copay 31
$36 copay 31
$20 copay 28
$30 copay 28
$36 copay 28
$20 copay
$30 copay
$36 copay
Not covered 31 Not covered


IMPORTANT!
Services under the Wellness and Preventive Care Services Benefits are not subject to a copay or annual deductible.

Compound medications will be subject to the preauthorization requirements. If any ingredient in a compound medication is on Express Scripts' list of excluded ingredients, ESI will work closely with the compounding pharmacy to replace or remove the non-covered ingredient.

Hepatitis C Medications will be subject to the preauthorization requirements.

1. For COBRA participants and Extended Coverage participants only.

2. Benefits for services received from a network provider will be paid based on the contracted rate.

3. Benefits for services received from non-network and out-of-area providers will be paid based on reasonable and customary (R&C) allowances. The participant is responsible for any amount over the R&C.

4. The participant must contact the Fund office to determine if the provider qualifies for the out-of-area benefit. If the provider is approved, the participant is responsible for filing claims with the Fund to receive benefit reimbursement.

10. See Wellness Benefits, page 12.

11. See Preventive Care Benefits Services, page 10. Some or all of the services in this section may be covered under the Preventive Care Service Benefits, payable at 100%, no deductible, when seen by a network provider.

26. Subject to coordination of benefits provision.

28. You must pay the full cost of the drug at the point of purchase. You will be reimbursed according to the plan's schedule of benefits when you submit your claim to Express Scripts.

29. Brand-name copay applies only when doctor specifies "Dispense As Written" (DAW) on the prescription and no generic equivalent is available. For non-covered drugs, see Express Scripts' website at www.express-scripts.com.

30. If a generic equivalent is available, patient pays generic copay plus the cost difference between generic drug and brand-name drug even if the doctor specifies "Dispense as Written" (DAW) on the prescription.

31. Over-the-counter drugs allowed under the Preventive Care Services Benefits are administered by Express Scripts. See list of eligible preventive care benefits, pages 70-72.

32. Using the mail-order service is mandatory for maintenance medications.