| |
Plan Features
Physician Services
Hospital Services
Other Medical Services
- Prescription Drugs
Mental Health & Substance Abuse
The Industry Health Network
Dental Plan Features
Important Telephone Numbers And Websites
|
REGULAR
PLAN PPO |
LOW
OPTION PLAN
(For COBRA Participants and Extended Coverage Participants Only) |
|
NETWORK
PROVIDER |
NON-NETWORK
PROVIDER |
OUT
OF AREA
(For participants residing outside the PPO service area only) |
NETWORK
PROVIDER |
NON-NETWORK
PROVIDER |
| PRESCRIPTION
DRUGS |
|
Retail
(up
to a 30-day supply only)
|
|
|
|
|
|
|
|
$10
copay |
$10
copay 1
|
$10
copay |
Not
covered |
Not
covered |
|
|
$15
copay |
$15
copay 1
|
$15
copay |
Not
covered |
Not
covered |
|
|
$25
copay |
$25
copay 1 |
$25
copay |
Not
covered |
Not
covered |
|
Mail
Order (up to a 90-day supply) 4
|
|
|
|
|
|
|
|
$20
copay |
$20
copay 1
|
$20
copay |
Not
covered |
Not
covered |
|
|
$30
copay |
$30
copay 1
|
$30
copay |
Not
covered |
Not
covered |
|
|
$36
copay |
$36
copay 1 |
$36
copay |
Not
covered |
Not
covered |
1. You
must pay the full cost of the drug at the point of purchase. You'll
be reimbursed according to the plan's schedule of benefits when you
submit your claim to the outside Claim Administrator.
2. Brand-name copay applies only when doctor specifies "Dispense
As Written" (DAW) on the prescription and no generic equivalent
is available.
3. If generic equivalent is available, pay generic copay plus the
cost difference between generic drug and brand-name drug even if the
doctor specifies "Dispense As Written" (DAW) on the prescription.
4.Using the mail-order service is mandatory for maintenance medications.
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