COPAY PRESCRIPTION DRUG PLAN
Pharmacy Benefits Manager
Eligibility
Employees, spouses, & dependents to age 19, full-time student dependents to age 25.
POS Co-pay Benefits
Participating Local Retail Pharmacy & CuraScript Specialty Pharmacy (see below)
Generic Drugs $5 co-pay, 30-day supply
Formulary Brand Name Drugs $20 co-pay, 30-day supply
Non-Formulary Brand Name Drugs $40 co-pay, 30-day supply
Home Delivery Pharmacy (for maintenance medications that treat chronic conditions)
Generic Drugs $10 co-pay, 90-day supply
Formulary Brand Name Drugs $40 co-pay, 90-day supply
Non-Formulary Brand Name Drugs $80 co-pay, 90-day supply
PPO Co-pay Benefits
Participating Local Retail Pharmacy & CuraScript Specialty Pharmacy (see below)
Generic Drugs $10 co-pay, 30-day supply
Formulary Brand Name Drugs $20 co-pay, 30-day supply
Non-Formulary Brand Name Drugs $30 co-pay, 30-day supply
Home Delivery Pharmacy (for maintenance medications that treat chronic conditions)
Generic Drugs $20 co-pay, 90-day supply
Formulary Brand Name Drugs $40 co-pay, 90-day supply
Non-Formulary Brand Name Drugs $60 co-pay, 90-day supply
Participating Retail Pharmacy Information
To locate participating retail pharmacies, visit the Express Scripts website at www.express-scripts.com.
Home Delivery Pharmacy Service
Send home delivery service profile form along with original prescription and applicable copay in self-addressed envelope found in your Express Scripts welcome packet. Allow 14 business days to receive your prescription.
CuraScript Specialty Pharmacy Information
Exclusive supplier of “specialty medications” (high-cost oral, injectable, infused or inhaled medications that may be self-administered), offering clinical support and therapy management and counseling. First prescription may be obtained at the retail pharmacy with subsequent prescriptions filled through CuraScript and delivered to your home.
General Exclusions
Medications lawfully obtained without a prescription/Devices or appliances –support garments or other non-medicinal substances/Administration charges for drugs or insulin/Investigational or experimental drugs/Unauthorized refills/Prescriptions covered without charge under Federal, State or local programs including Workers’ Compensation/Medications for eligibles confined to a rest home, nursing home, sanitarium, extended care facility, hospital or similar entity/Medication used for cosmetic purposes.
This summary does not detail all benefits, limitations or exclusions. All benefits subject to coordination of benefits (COB). 9/08