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PRODUCERS - PHARMACY PLANS
New Rx Plans Effective 5/1/04
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| AT-A-GLANCE | ||||||||
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When To |
For immediate drug needs or short-term medications |
For maintenance of long-term medications |
For immediate drug needs or short-term medications |
For maintenance of long-term medications |
For immediate drug needs or short-term medications |
For maintenance of long-term medications |
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You Pay |
$5.00 for each generic prescription $15.00 for each formulary brand name* prescription $50.00 for each non-formulary brand name* prescription 25% coinsurance per 30 day supply for speciality drugs. |
$10.00 for each generic prescription $30.00 for each formulary brand name* prescription $100.00 for each non-formulary brand name* prescription |
$10.00 for each generic prescription $25.00 for each formulary brand name* prescription $50.00 for each non-formulary brand name* prescription 25% coinsurance per 30 day supply for speciality drugs. |
$20.00 for each generic prescription $50.00 for each formulary brand name* prescription $100.00 for each non-formulary brand name* prescription |
$15.00 for each generic prescription $35.00 for each formulary brand name* prescription $70.00 for each non-formulary brand name* prescription 25% coinsurance per 30 day supply for speciality drugs. |
$30.00 for each generic prescription $70.00 for each formulary brand name* prescription $140.00 for each non-formulary brand name* prescription |
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| Out of Pocket Maximum |
$5,000 for specialty drugs.
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Days Supply Limit |
30-day supply |
90-day supply |
30-day supply |
90-day supply |
30-day supply |
90-day supply |
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Refill Limit |
One refill on maintenance medication only |
None |
One refill on maintenance medication only |
None |
One refill on maintenance medication only |
None |
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Old Plans
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| AT-A-GLANCE | ||||||||
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When To |
For immediate drug needs or short-term medications |
For maintenance of long-term medications |
For immediate drug needs or short-term medications |
For maintenance of long-term medications |
For immediate drug needs or short-term medications |
For maintenance of long-term medications | ||
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You Pay |
$5.00 for each generic prescription $15.00 for each formulary brand name* prescription $50.00 for each non-formulary brand name* prescription |
$10.00 for each generic prescription $30.00 for each formulary brand name* prescription $100.00 for each non-formulary brand name* prescription |
$10.00 for each generic prescription $25.00 for each formulary brand name* prescription $50.00 for each non-formulary brand name* prescription |
$20.00 for each generic prescription $40.00 for each formulary brand name* prescription $100.00 for each non-formulary brand name* prescription |
$15.00 for each generic prescription $35.00 for each formulary brand name* prescription $50.00 for each non-formulary brand name* prescription |
$30.00 for each generic prescription $70.00 for each formulary brand name* prescription $100.00 for each non-formulary brand name* prescription | ||
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Days Supply Limit |
30-day supply |
90-day supply |
30-day supply |
90-day supply |
30-day supply |
90-day supply | ||
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Refill Limit |
One refill on maintenance medication only |
None |
One refill on maintenance medication only |
None |
One refill on maintenance medication only |
None | ||
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