Mandatory generic substitution. ▪ The program will continue to provide same coverage on medication as the one in effect prior to the expiration of the previous agreement. However, the refund to the employee will be limited to the price of the generic drug as long as it is available. If it’s not available, the brand name will be covered. If an employee is allergic to a generic drug, he will be eligible to the brand name drug.
Mandatory generic substitution. Some prescription drugs require Prior Authorization. Prior Authorization is a tool used to ensure that you will achieve the maximum clinical benefit from the use of specific targeted drugs. Your physician or pharmacist must call (000) 000-0000 to begin the prior authorization process. For the most up-to-date prior authorization list, visit the prescription drug website at xxxxxxxxx.xxx/xxxxxxx. If you choose a Non-preferred Brand drug (Tier 3) instead of its Generic equivalent, you will pay the highest copay plus, the difference in cost between the Non-preferred Brand drug and the Generic. If a Generic version is not available, you will only pay the copay. BlueDental Plus–PPO Comprehensive Summary of Benefits Includes access to a national provider network In-Network You Pay Out-of-Network You Pay DEDUCTIBLE APPLIES TO ALL BASIC AND MAJOR SERVICES* $25 Individual/ $50 Family $50 Individual/ $150 Family ANNUAL MAXIMUM APPLIES TO ALL BASIC AND MAJOR SERVICES* Plan pays $1,500 maximum PREVENTIVE & DIAGNOSTIC SERVICES ■ Oral Exams ■ Prophylaxis ■ X-rays ■ Sealants No charge1 35% of Allowed Benefit; Deductible does not apply; Non-participating providers may bill for the difference between the allowed benefit and the provider’s charges.1 BASIC SERVICES ■ Fillings—includes posterior composite restorations ■ Periodontics (gum treatment) ■ Endodontics (root canals) ■ Denture repair/relining ■ Stainless steel crowns ■ Bridges, bridge recementation/repair ■ Implants—covered only as an alternative to a fixed bridge ■ Oral surgery 20% of Allowed Benefit after deductible1 50% of Allowed Benefit after deductible; Non-participating providers may bill for the difference between the allowed benefit and the provider’s charges1 ■ Surgical removal of impacted teeth No charge after deductible1 35% of Allowed Benefit after deductible; Non-participating providers may bill for the difference between the allowed benefit and the provider’s charges.1 MAJOR SERVICES ■ Dentures ■ Crowns, inlays, onlays and cast restorations 50% of Allowed Benefit after deductible1 70% of Allowed Benefit after deductible; Non-participating providers may bill for the difference between the allowed benefit and the provider’s charges.1 ORTHODONTIC SERVICES ■ Benefits for orthodontic services are available for dependent children up to age 19 50% of Allowed Benefit1 50% of Allowed Benefit; Deductible does not apply; Non-participating providers may bill for the difference between the allowed benefit and the pr...
Mandatory generic substitution. Failure to get generic when available will result in the member paying the difference in cost between the generic drug and the brand name drug plus the brand name drug copay. The mail order drug program has been enhanced to allow the member to receive a 3 month supply of generic medication for just one generic drug copay. The PPO Dental plan benefits cover a wide range of dental services. You have the freedom to go in and out of network for care. You may visit a PPO dentist and benefit from the reduced contracted fee resulting in less out of pocket expense. You may also visit an out of network dentist, where services will be based on a reasonable and customary amount and you will be responsible for any amount owed after insurance has paid. Calendar Year Maximum $ 1,500 $ 1,500 Deductible (Ind. / Family) $ 50 / $150 $ 50 / $150 Preventive 100% Deductible Waived for Preventive Services? Yes Basic Services 90 % 80 % Major Services 60 % 50 % Orthodontia (child only) 50 % 50 % Orthodontia Lifetime Max $1,500 The Vision Service Plan (VSP) provides professional vision care and high quality lenses and frames through a broad network of optical specialists. Examination $20 Prescription Glasses $20 Contact Lenses No Copay Single Vision 100 % $45 Benefit Bifocal 100 % $65 Benefit Trifocal 100 % $85 Benefit Frame $120 Benefit $47 Benefit Contact Lenses $120 Benefit $105 Benefit Exam 12 months Lenses 12 months Frames 24 months Award Metals provides full-time hourly employees with Basic Term Life and Accidental Death & Dismemberment (AD&D) insurance through Prudential Financial. The Basic Term Life benefit is $10,000. The AD&D benefit matches the Basic Term Life benefit. The AD&D benefit includes benefits for loss of life or limbs due to an accident. Award Metals also provides full-time salaried employees with Basic Term Life insurance for their dependents through Prudential Financial. The Basic Term Life benefit is $5,000 for a spouse and $1,000 for each dependent child. You may elect to purchase additional Term Life insurance at group rates provided by Prudential Financial. You pay for this coverage with after-tax dollars through payroll deduction. Benefits are available to employees in increments of $10,000 up to $500,000. Coverage for your spouse and child(ren) is also available. For more information, contact your Human Resources Dept. Award Metals also provides Short-Term Disability coverage which may replace up to 60% of your income for up to twelve weeks, in the e...
Mandatory generic substitution. Only expenses for the least expensive drug equivalent to the drug prescribed are eligible, even if the healthcare professional has indicated on the prescription that no substitutions are to be made. Insureds wishing to be reimbursed based on the cost of the brand name drug or another generic must obtain the appropriate form from the Insurer and have it completed by their healthcare professional, specifying the medical contraindications associated with the least costly generic. The insured must then submit this form to the Insurer for analysis. Prescription drug refills for the drug that has been accepted by the Insurer will then be approved through the Insurer’s electronic transmission system. The medical form need not be completed again.
