Out-of-Network Pharmacies. For out-of-network pharmacies, an employee will pay 100% of the cost difference between the retail cost and the DNP. In addition, an employee will pay a percentage of the DNP, as provided below. After the $50 per person out-of-network annual deductible is met, the following prescription drug coverage will apply for prescription drugs purchased at out-of-network pharmacies for up to a 30-day supply: • The copay for generic drugs will be 30% of the DNP for the original prescription and each refill. • The copay for brand name preferred drugs will be 40% of the DNP for the original prescription and each refill. • The copay for brand name non-preferred drugs will be 40% of the DNP for the original prescription and each refill. • If an employee purchases a brand name drug when a generic equivalent is available, the employee will pay 30% of the DNP plus 100% of the cost difference between the brand name and generic drug, unless the employee’s treating physician certifies that the employee is medically unable to take the generic medication and such exception is approved by the TPA’s procedures for approval of treatment or services, then the brand name preferred or brand name non-preferred coverage will apply, as applicable. • Once an employee has obtained three fills of the prescription from an out-of- network pharmacy (i.e., the initial prescription plus two refills), then the employee must use the mail order pharmacy to obtain subsequent refills of long-term prescription medications. If an employee does not use the mail order pharmacy to obtain such subsequent refills of a long-term prescription medication, an employee will be responsible for 50% of the DNP cost for subsequent refills of a long-term prescription medication.
