Five-Tier Copayment Structure. This prescription drug plan formulary has a five-tiered copayment structure. The copayment for a prescription drug will vary by tier. The tier placement of a prescription drug on our formulary is subject to change. For more information about our formulary, and to see the tier placement of a particular prescription drug, visit our website or call our Customer Service Department. Below indicates the tier structure for this plan and the amount that you are responsible to pay. You will be responsible for paying the lowest cost of either your copayment, the retail cost of the drug, or the pharmacy allowance. We reserve the right not to accept manufacturer coupons, discount plan payments or other cost share assistance program payments for prescription drug copayments and/or deductibles. HSA Preventive Drug List This plan allows for certain preventive prescriptions drugs to be covered, with a copayment, before meeting your plan year deductible. See the Summary of Pharmacy Benefits for the applicable copayment. For a list of these preventive prescription drugs, please visit our website or call our Customer Service Department. Summary of Pharmacy Benefits
Appears in 8 contracts
Samples: Subscriber Agreement, Subscriber Agreement, Subscriber Agreement
Five-Tier Copayment Structure. This prescription drug plan formulary has a five-tiered copayment structure. The copayment for a prescription drug will vary by tier. The tier placement of a prescription drug on our formulary is subject to change. For more information about our formulary, and to see the tier placement of a particular prescription drug, visit our website or call our Customer Service Department. Below indicates the tier structure for this plan and the amount that you are responsible to pay. You will be responsible for paying the lowest cost of either your copayment, the retail cost of the drug, or the pharmacy allowance. We reserve the right not to accept manufacturer coupons, discount plan payments or other cost share assistance program payments for prescription drug copayments and/or deductibles. HSA Preventive Drug List This plan allows for certain preventive prescriptions drugs to be covered, with a copayment, before meeting your plan year deductible. See the Summary of Pharmacy Benefits for the applicable copayment. For a list of these preventive prescription drugs, please visit our website or call our Customer Service Department. SG-COC-2-2021-BX & SG-SOB-13-2021-BX 7 BlueSolutions for HSA Summary of Pharmacy Benefits
Appears in 1 contract
Samples: Subscriber Agreement
