YOUR COST FOR PRESCRIPTION DRUGS. How Your Cost is Determined The amount that you are responsible for is based upon the drug tier as described below and shown in the Benefit Highlights section of this Certificate • Tier 1 - includes mostly Generic Drugs and may contain some Brand Name Drugs. • Tier 2 - includes mostly Preferred Brand Name Drugs and may contain some Generic Drugs. • Tier 3 - includes mostly Non-Preferred Brand Name Drugs and may contain some Generic Drugs. To verify your payment amount for a drug, visit the Plan's website at xxx.xxxxxx.xxx and log into Blue Access for Members or call the number on the back of your identification card. Benefits will be provided as shown in the Benefit Highlights section of this Certificate. Out‐of‐Pocket Expense Limit Expenses incurred by you for Covered Services under this benefit section will be applied towards the Covered Services Expense Limitation described in the OTHER THINGS YOU SHOULD KNOW section of this Certificate. If dur ing one calendar year your Covered Services Expense Limitation is reached, benefits will be available for any additional eligible Claims for drugs and dia betic supplies obtained during that calendar year and will be paid in full at no cost to you. If during one calendar year, your out‐of‐pocket expense (the amount remaining unpaid after benefits have been provided) for Outpatient prescription drugs and diabetic supplies equals $500, any additional eligible Claims for Outpatient pre scription drugs and diabetic supplies during that calendar year will be paid in full at no cost to you. If you have Family Coverage and your out‐of‐pocket expense (the amount re maining unpaid after benefits have been provided) for Outpatient prescription drugs and diabetic supplies equals $1,000 during one calendar year, then for the rest of that calendar year, all other family members will have benefits paid in full at no cost to them. A family member may not apply more than the individu al out‐of‐pocket expense limit toward this amount.
YOUR COST FOR PRESCRIPTION DRUGS. How Your Cost is Determined The amount that you are responsible for is based upon the drug tier as described below and shown in the Benefit Highlights section of this Certificate • Tier 1 - includes mostly Generic Drugs and may contain some Brand Name Drugs. • Tier 2 - includes mostly Preferred Brand Name Drugs and may contain some Generic Drugs. • Tier 3 - includes mostly Non-Preferred Brand Name Drugs and may contain some Generic Drugs. If you or your Provider requests a Brand Name Drug when a generic or thera peutic equivalent is available, you will be responsible for the Non‐Preferred Brand Name Drug payment amount, plus the difference in cost between the Brand Name Drug and the generic equivalent, except as provided in this Certi ficate. To verify your payment amount for a drug, visit the Plan's website at xxx.xxxxxx.xxx and log into Blue Access for Members or call the number on the back of your identification card. Benefits will be provided as shown in the Benefit Highlights section of this Certificate.
YOUR COST FOR PRESCRIPTION DRUGS. 30‐Day Supply Prescription Drug Program Benefit payment for the 30‐day supply prescription drug program The benefits you receive and the amount you pay for drugs will differ depending upon the type of drugs, or diabetic supplies or insulin and insulin syringes you pur chase, whether or not the drug is self‐injectable and whether or not the drug is purchased from a Participating Pharmacy. When you purchase drugs or diabetic supplies from a Participating Prescription Drug Provider, you will not be charged any amount other than the specified amounts shown in the BENEFIT HIGHLIGHTS section of this Certificate. You will be charged the appropriate amount for each prescription. One prescription means up to a 30 consecutive day supply for most medications. Certain drugs may be limited to less than a 30 consecutive day supply. However, for certain maintenance type drugs, larger quantities may be obtained through the 90‐day supply prescription drug program. Specific information on these maintenance drugs can be obtained from a Prescription Drug Provider particip ating in the 90‐day supply prescription drug program or the Plan. Benefits for prescription inhalants will not be restricted on the number of days before an in xxxxx refill may be obtained. No benefits will be provided when you purchase drugs or diabetic supplies from a Non‐Participating Prescription Drug Provider (other than a Participating Pre scription Drug Provider) in Illinois. However, if the Non‐Participating Prescription Drug Provider is located outside of Illinois, then benefits for drugs or diabetic supplies purchased for emergency conditions will be provided and you will be responsible for the specified Coinsurance or Copayment amount shown in the BENEFIT HIGHLIGHTS section of this Certificate. You will be charged the appropriate Coinsurance or Copayment amount for each prescrip tion.
