Pharmacy Benefits
Pharmacy Plan Details
Pharmacy Network
Standard Select
Prescription Drug List
Advantage
In Network
Annual Pharmacy Deductible
Individual
You do not have to pay a pharmacy deductible
Family
You do not have to pay a pharmacy deductible
Up to a 31-day supply
Up to a 90-day supply
Prescription Drug Product Tier Level
Mail Order Network Pharmacy**
Retail Network***
Out-of-Network Pharmacy
Tier 1 $ Tier 2 $$ Tier 3 $$$ Tier 4 $$$$
$10
$10
$25
$35
$35
$87.50
$75
$75
$187.50
$250
$250
$625
Mail Order Preferred Specialty Network Pharmacy**
Preferred Specialty Prescription Drug Product Tier Level
Preferred Specialty Retail Network
Preferred Specialty Out-of- Network Pharmacy
Tier 1 $ Tier 2 $$ Tier 3 $$$ Tier 4 $$$$
$10
$10
Not applicable
$150
$150
Not applicable
$350
$350
Not applicable
$500
$500
Not applicable
** Only certain Prescription Drug Products are available through mail order; please visit myuhc.com® or call Customer Care at the telephone number on the back of your ID card for more information. You will be charged a retail Copayment and/or Coinsurance for 31 days or 2 times for 60 days based on the number of days supply dispensed for any Prescription Order or Refills sent to the mail order pharmacy. To maximize your Benefit, ask your Physician to write your Prescription Order or Refill for a 90-day supply, with refills when appropriate, rather than a 30-day supply with three refills. ***Retail: up to a 90 day supply. You will be charged a retail Copayment and/or Coinsurance for 31 days, 2 times for 60 days, or 3 times for 90 days based on the number of days supply dispensed for any Prescription Order or Refills obtained at a retail pharmacy. Your Copayment and/or Coinsurance is determined by the tier to which the Prescription Drug List (PDL) Management Committee has assigned the Prescription Drug Product. All Prescription Drug Products on the Prescription Drug List are assigned to Tier 1, Tier 2, Tier 3 or Tier 4. If you are a member, you can find individualized information on your benefit coverage, determine tier status, check the status of claims and search for network pharmacies by logging into your account on myuhc.com® or calling the Customer Care number on your ID card. If you are not a member, you can view prescription information at welcometouhc.com > Benefits > Pharmacy Benefits.
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