PRESCRIPTION BENEFIT
POS Plan
Plan Features
IN NETWORK
Copay/Prescription deductible doesn’t apply $15 retail, $30 mail order
Generic Drugs
Copay/Prescription deductible doesn’t apply $25 retail, $50 mail order
Preferred Brand Drugs
Copay/Prescription deductible doesn’t apply $40 retail, $80 mail order
Non-Preferred Brand Drugs
Applicable cost as noted above for generic or brand drugs
Specialty Drugs
Covers 30 day supply (retail), 31-90 day supply (mail order). Includes contraceptive drugs & devices obtainable from a pharmacy, oral & injectable fertility drugs. No charge for preferred generic FDA-approved women's contraceptives in-network. Review your formulary for prescriptions requiring precertification or step therapy for coverage. OOPM will be separate from medical OOPM. If you have any questions please contact customer services for Capital Rx at 855-227-7928
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MEDICAL PLAN I
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