SUMMARY OF PHARMACY BENEFITS. The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty, pharmacy. For information about our pharmacy network, visit our website or call our Customer Service Department.
SUMMARY OF PHARMACY BENEFITS. Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for this service. Please see Preauthorization in Section 3 for more information. You Pay You Pay Prescription Drugs, other than Specialty Prescription Drugs, and Diabetic Equipment and Suppliesw( hich includes Glucometers, Test Strips, Lancet and Lancet Devices, Needles and Syringes, and Miscellaneous Suppl calibration fluid): When purchased at a Retail or Spaelctiy Pharmacy: Copaymentapplies per each 3-0day supply or portion thereof for maintenance and n-omnaintenance prescription drugs. For tiers 1, 2, and 3: Up to a -9d0ay supply of maintenance and no-nmaintenance prescription drugs is available at certain retail pharmacies. For -ad9ay0 supply; three retail copayments apply. For more information about pharmacies offering this optisoitn, our website. Proratedcopaymentsfor a shorter supply period may apply fornetwork pharmacoynly. See Prescription Drug section for details. Tier 1: $10 Not Covered Tier 2: $35 Not Covered Tier 3: $70 Not Covered Tier4 and Tier5: See specialty prescription drug section below. Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply of maintenance and n-on maintenance prescription drugs. Tier 1: $25 Not Covered Tier 2: $87.50 Not Covered Tier 3: $210 Not Covered Tier4 and Tier5: See specialty prescription drug section below. Not Covered Specialty Prescription Drugs (+)Prorated copayments for a shorter supply period may apply nfoetrwork pharmacy only. See Prescrpition Drug section for details. When purchased at a Specialty Pharmacy(+): Copaymentapplies per each 3-0day supply or applies per recommended treatment interval. Tier4: $150 Not Covered Tier5: $300 Not Covered When purchased at a Retail Pharmacy(+): Copaymentapplies per each 3-0day supply or applies per recommended treatment intervSapl.ecialty Prescription Drugpsurchased at a ertailpharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier4: 50% Not Covered Tier5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Infertility Prescription Drugs- Three (3) i-nvitro cycles will be covered perplan yearwith a total of eight (8)-viintro cycles covered in a P H liPfetimE e. H U ¶ V When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% NotCovered Tier 2: 20% Not Covered Tier 3:20% Not Covered When purchased at a ...
SUMMARY OF PHARMACY BENEFITS. Covered Benefits Network Pharmacy Non-network Pharmacy
SUMMARY OF PHARMACY BENEFITS. Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for this service. Please see Preauthorization in Section 3 for more information. You Pay You Pay
SUMMARY OF PHARMACY BENEFITS. Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Ground $50 The level of coverage is the same as network provider. Air/water* $50 The level of coverage is the same as network provider.
