OUTPATIENT PRESCRIPTION DRUG PROGRAM BENEFITS. When you are being treated for an illness or accident, your Physician may pre scribe certain drugs or medicines as part of your treatment. Your coverage includes benefits for drugs and supplies which are self‐administered. Benefits will not be provided for any self‐administered drugs dispensed by a Physician. This section of your Certificate explains which drugs and supplies are covered and the benefits that are available for them. Benefits will be provided only if such drugs and supplies are medically necessary. Although you can go to the Pharmacy of your choice, benefits will only be provided for drugs and supplies when purchased through a Participating Phar macy. However, benefits for drugs and supplies purchased outside of a Participating Pharmacy network will only be provided in the case of an emer gency condition. You can visit the Plan's website at xxx.xxxxxx.xxx for a list of Participating Pharmacies or call the customer service toll‐free number on your identification card. The Pharmacies that are Participating or Specialty Pharma cies may change from time to time. You should check with your Pharmacy before obtaining drugs or supplies to make certain of its participation status. The benefits of this section are subject to all of the terms and conditions of this Certificate. Please refer to the DEFINITIONS, ELIGIBILITY and EXCLU SIONS — WHAT IS NOT COVERED sections of this Certificate for additional information regarding any limitations and/or special conditions pertaining to your benefits.
OUTPATIENT PRESCRIPTION DRUG PROGRAM BENEFITS. When you are being treated for an illness or accident, your Physician may pre scribe certain drugs or medicines as part of your treatment. Your coverage includes benefits for drugs and supplies which are self‐administered. This sec tion of your Certificate explains which drugs and supplies are covered and the benefits that are available for them. Benefits will be provided only if such drugs and supplies are Medically Necessary. Although you can go to the Pharmacy of your choice, your benefits for drugs and supplies will be greater when you obtain them from a Participating Pharma cy. You can visit the Plan's Web site at xxx.xxxxxx.xxx for a list of Participating Pharmacies or call the Customer Service toll‐free number on your identification card. The Pharmacies that are Participating Pharmacies may change from time to time. You should check with your Pharmacy before obtaining drugs or sup plies to make certain of its participation status. The benefits of this section are subject to all of the terms and conditions of this Certificate. Please refer to the DEFINITIONS, ELIGIBILITY and EXCLU SIONS — WHAT IS NOT COVERED sections of this Certificate for additional information regarding any limitations and/or special conditions pertaining to your benefits. For purposes of this benefit section only, the following definitions shall apply: BRAND NAME DRUG. means a drug or product manufactured by a single manufacturer as defined by a nationally recognized provider of drug product database information. There may be some cases where two manufacturers will produce the same product under one license, known as a co‐licensed product, which would also be considered as a Brand Name Drug. There may also be situations where a drug's classification changes from Generic to For mulary or Non‐Formulary Brand Name due to a change in the market resulting in the Generic Drug being a single source, or the drug product data base information changing, which would also result in a corresponding change to your payment obligations from Generic to Formulary or Non‐For mulary Brand Name. COINSURANCE AMOUNT.....means the percentage amount paid by you for each Prescription Order filled or refilled through a Participating Pharma cy or non‐Participating Pharmacy.
OUTPATIENT PRESCRIPTION DRUG PROGRAM BENEFITS. When you are being treated for an illness or accident, your Physician may pre scribe certain drugs or medicines as part of your treatment. Your coverage includes benefits for drugs and supplies which are self‐administered. Benefits will not be provided for any self‐administered drugs dispensed by a Physician. This section of your Certificate explains which drugs and supplies are covered and the benefits that are available for them. Benefits will be provided only if such drugs and supplies are medically necessary as determined by your Primary Care Physician or Woman's Principal Health Care Provider. Although you can go to the Pharmacy of your choice, benefits will only be provided for drugs and supplies when purchased through a Participating Phar macy. However, benefits for drugs and supplies when purchased outside of a Participating Pharmacy network will only be provided in the case of an emer gency condition. You can visit the Plan's Web site at xxx.xxxxxx.xxx for a list of Participating Pharmacies or call the customer service toll‐free number on your identification card. The Pharmacies that are Participating Pharmacies may change from time to time. You should check with your Pharmacy before obtaining drugs or supplies to make certain of its participation status. The benefits of this section are subject to all of the terms and conditions of this Certificate. Please refer to the DEFINITIONS, ELIGIBILITY and EXCLU SIONS — WHAT IS NOT COVERED sections of this Certificate for additional information regarding any limitations and/or special conditions pertaining to your benefits.
OUTPATIENT PRESCRIPTION DRUG PROGRAM BENEFITS. Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Participating in the 34‐Day Supply Prescription Drug Program: — Generic Drugs, insulin and insulin syringes $8 per Prescription — Formulary Brand‐name Drugs $20 per Prescription — Non‐Formulary Brand‐name Drugs $35 per Prescription — Self‐Injectable Drugs other than Insulin and Infertility Drugs $50 per Prescription — Diabetic Supplies None — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Not Participating in the 34‐Day Supply Pre scription Drug Program: — For drugs or diabetic supplies purchased within Illinois: No benefits will be provided for drugs or diabetic supplies purchased from a Non‐Participating Prescription Drug Provider. — For drugs or diabetic supplies purchased outside Illinois: The appropriate Copayment(s) or Coinsurance indicated above plus any difference between the Participating Provider's Charge and the Non‐Participating Provider's Charge for drugs prescribed for emer gency conditions. — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Participating in the 90‐Day Supply Prescription Drug Program: — Generic Drugs, insulin and insulin syringes $16 per Prescription — Formulary Brand‐name Drugs $40 per Prescription — Non‐Formulary Brand‐name Drugs $70 per Prescription — Self‐Injectable Drugs other than Insulin and Infertility Drugs $50 per Prescription — Diabetic Supplies None GB‐16 HCSC 3 — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Not Participating in the 90‐Day Supply Pre scription Drug Program: — No benefits will be provided for drugs or diabetic supplies purchased from a Prescription Drug Provider not participating in the 90‐day sup ply program. — Individual Out‐of‐Pocket Expense Limit for prescription drugs and diabetic supplies $5,100 per Calendar Year* — Family Out‐of‐Pocket Expense Limit for prescription drugs and diabetic supplies $10,200 per Calendar Year* *Applies towards the Covered Services Expense Limitation (See the OTHER THINGS YOU SHOULD KNOW section of this Certific ate.) LIMITING AGE FOR DEPENDENT CHILDREN 26 GB‐16 HCSC 4 ELIGIBILITY Changes in state or federal law or regulations or interpretations thereof may change the terms and conditions of coverage. Subject to the other terms and conditions of the Group Policy, the benefits de scribed in this Certificate wi...
