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SCHEDULE OF BENEFITS

Retail, network pharmacy (up to a 30 day supply)

Mail Order The Medco Pharmacy (up to a 90 day supply)

Generics

$10

$20

Brands: preferred / formulary

20% of prescription cost Minimum $30 Maximum $50

20% of prescription cost Minimum $60 Maximum $100

Brands: non-preferred / non-formulary

40% of prescription cost Minimum $50 Maximum $70

40% of prescription cost Minimum $100 Maximum $140

State of Indiana Prescription benefit plan design TRADITIONAL PPO

Specialty drugs

Retail and Mail Order (up to a 30 day supply)

40% of prescription cost Minimum $75 Maximum $150

Deductible (combined Rx + medical accumulator):

  • *

    $ 750 single / $ 1500 family

    • *

      prescription drug copayments/coinsurance are subject to the deductible.

Out-of-pocket/OOP limit (combined Rx + medical accumulator):

  • *

    $2000 single / $4000 family

    • *

      prescription drug copayments/coinsurance are subject to the OOP limit; once the member

and/or family OOP limit is satisfied, no additional copayments/coinsurance are required for the remainder of the calendar year. Retail out-of-network claims (direct) are reimbursed based on copays above and member also pays any difference between the pharmacy charge and the allowable costs

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11/1/10

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