and it will be no more than the lesser of your scheduled copayment/coinsurance amount or the Maximum Allowable Amount. Please see the Schedule of Benefits for any applicable deductible and coinsurance/copayment. If you receive Covered Services from a non-network pharmacy, a deductible and coinsurance/copayment amount may also apply.
Days Supply The number of days supply of a drug that you may receive is limited. The days supply limit applicable to prescription drug coverage is shown in the Schedule of Benefits. If you are going on vacation and you need more than the days supply allowed for a retail prescription under this Plan, you should ask your retail pharmacist. If your prescription is through mail order (the Medco Pharmacy or Accredo), call Medco and request an override for one additional refill. This will allow you to fill your next prescription early. If you require more than one extra refill, please call the Customer Service telephone number on the back of your ID card.
Days supply may be less than the amount shown in the Schedule of Benefits due to Prior Authorization, Quantity Limits, and/or age limits and Utilization Guidelines.
Tiers Your copayment/coinsurance amount may vary based on whether the prescription drug, including covered Specialty Drugs, has been classified by the Plan as a first, or second, or third, or fourth “tier” drug. The determination of tiers is made by the Plan, on behalf of the Employer, based upon clinical information, and, where appropriate, the cost of the drug relative to other drugs in its therapeutic class or used to treat the same or similar condition, the availability of over-the-counter alternatives, and certain clinical economic factors. Tier 1 generally includes generic prescription drugs. Tier 2 generally includes brand name or generic drugs that based upon their clinical information, and where appropriate, cost considerations are preferred relative to other Drugs. Tier 3 generally includes brand name or certain generic drugs that based upon their clinical information, and where appropriate, cost considerations are not preferred relative to other drugs in lower tiers. Tier 4 generally includes injectable, specialty drugs. To see if a drug is in the 4th tier, call Medco at the number on the back of your ID card or access www.medco.com to price your medication.
Special Programs From time to time the Plan may initiate various programs to encourage the use of more cost- effective or clinically-effective Prescription drugs including, but not limited to, generic drugs, mail service drugs, over the counter or preferred products. Such programs may involve reducing or waiving copayments or coinsurance for certain drugs or preferred products for a limited period of time.
Payment of Benefits The amount of benefits paid is based upon whether you receive the Covered Services from a retail pharmacy, a specialty pharmacy, a non-network retail pharmacy, or the Medco Pharmacy Mail Service program. It is also based upon the Tier classified by the Plan for the prescription
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