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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 CONSUMER DRIVEN HEALTH PLAN 2

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):

  • *

    $1500 single / $3000 family

    • *

      prescription drug copayments/coinsurance are subject to the deductible.

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

  • *

    $3000 single / $6000 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

Prior Authorization Prior Authorization may be required for certain prescription drugs (or the prescribed quantity of a particular Drug). Prior Authorization helps promote appropriate utilization and enforcement of guidelines for prescription drug benefit coverage. At the time you fill a prescription, the pharmacist is informed of the Prior Authorization requirement through the pharmacy’s computer

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