What You Will Pay
Common Medical Event
Limitations, Exceptions, & Other Important Information
Services You May Need
In-Network Provider (You will pay the least)
Out-of-Network Provider (You will pay the most)
20% coinsurance /prescription (retail 30 days), 20% coinsurance / p rescription (home delivery 90 days)
Generic drugs (Tier 1)
Not covered
2 0% coinsurance / prescription (retail 30 days), 20 % coinsurance / pr escription ( home delivery 90 days)
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.express-scripts.com/rx
If you elect to fill a brand name drug when there is a generic available, you will pay the brand drug cost plus the difference between the brand and generic drug cost.
Preferred brand drugs (Tier 2)
Not covered
2 0% coinsurance /prescription (retail 30 days) 20 % coinsurance /prescription (home delivery 90 days)
Non-preferred brand drugs (Tier 3)
Not covered
Page 3 of 8
Made with FlippingBook - Online magazine maker