Common use of Prescription Drugs Clause in Contracts

Prescription Drugs. $10 copayment per prescription or refill for up to a 30 day supply of Generic Plus drugs. A copay is incurred for each type of insulin. • $30 copayment per prescription or refill for up to a 30 day supply of all other formulary brand drugs. A copay is incurred for each type of insulin. • $75 copayment per prescription or refill for up to a 30 day supply of non-formulary drugs. • If a chemically equivalent generic drug is available and the employee takes the brand drug, the employee pays the generic copay and the difference in cost between the brand drug and generic drug. • Annual out of pocket (OOP) maximum for prescription drug copayments of $750 per person or $1500 per family. Copayments for the cost difference between generic and brand name drugs do not count against this annual OOP maximum.

Prescription Drugs.  $10 copayment per prescription or refill for up to a 30 day supply of Generic Plus drugs. A copay is incurred for each type of insulin. •  $30 copayment per prescription or refill for up to a 30 day supply of all other formulary brand drugs. A copay is incurred for each type of insulin. •  $75 copayment per prescription or refill for up to a 30 day supply of non-formulary drugs. •  If a chemically equivalent generic drug is available and the employee takes the brand drug, the employee pays the generic copay and the difference in cost between the brand drug and generic drug. •  Annual out of pocket (OOP) maximum for prescription drug copayments of $750 per person or $1500 per family. Copayments for the cost difference between generic and brand name drugs do not count against this annual OOP maximum.

Prescription Drugs. $10 8 copayment per prescription or refill for up to a 30 day supply of Generic Plus drugs. A copay is incurred for each type of insulin. • $30 20 copayment per prescription or refill for up to a 30 day supply of all other formulary brand drugs. A copay is incurred for each type of insulin. • $75 35 copayment per prescription or refill for up to a 30 day supply of non-formulary drugs. • If a chemically equivalent generic drug is available and the employee takes the brand drug, the employee pays the generic copay and the difference in cost between the brand drug and generic drug. • Annual out of pocket (OOP) maximum for prescription drug copayments of $750 per person or $1500 per family. Copayments for the cost difference between generic and brand name drugs do not count against this annual OOP maximum.

Prescription Drugs.  $10 8 copayment per prescription or refill for up to a 30 day supply of Generic Plus drugs. A copay is incurred for each type of insulin. •  $30 25 copayment per prescription or refill for up to a 30 day supply of all other formulary brand drugs. A copay is incurred for each type of insulin. •  $75 50 copayment per prescription or refill for up to a 30 day supply of non-non- formulary drugs. •  If a chemically equivalent generic drug is available and the employee takes the brand drug, the employee pays the generic copay and the difference in cost between the brand drug and generic drug. •  Annual out of pocket (OOP) maximum for prescription drug copayments of $750 per person or $1500 per family. Copayments for the cost difference between generic and brand name drugs do not count against this annual OOP maximum.

Prescription Drugs.  $10 copayment per prescription or refill for up to a 30 day supply of Generic Plus drugs. A copay is incurred for each type of insulin. •  $30 copayment per prescription or refill for up to a 30 day supply of all other formulary brand drugs. A copay is incurred for each type of insulin. •  $75 60 copayment per prescription or refill for up to a 30 day supply of non-non- formulary drugs. •  If a chemically equivalent generic drug is available and the employee takes the brand drug, the employee pays the generic copay and the difference in cost between the brand drug and generic drug. •  Annual out of pocket (OOP) maximum for prescription drug copayments of $750 per person or $1500 per family. Copayments for the cost difference between generic and brand name drugs do not count against this annual OOP maximum.

Prescription Drugs. $10 copayment per prescription or refill for up to a 30 34 day supply of Generic Plus formulary drugs. A copay is incurred for each type of insulin. • $30 20 copayment per prescription or refill for up to a 30 34 day supply of all other non- formulary brand drugs. A copay is incurred for each type of insulin. • $75 35 copayment per prescription or refill for up to a 30 34 day supply of non-formulary lifestyle drugs. • If For a chemically equivalent brand name drug where a generic drug is available and the employee takes the brand drugavailable, the employee member pays the generic copay and copayment plus the difference in cost between the brand drug generic and generic drugthe brand. • Annual out of pocket (OOP) maximum for prescription drug copayments of $750 400 per person ($500 per person in 2003) or $1500 800 per familyfamily ($1000 per family in 2003). Copayments for the cost difference between generic and brand name drugs do not count against this annual OOP maximum. Copayments for lifestyle drugs do not count against this annual OOP maximum.