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ME D ICAL MUTUAr
<br />Proecrintinn Ilnin Card Ranofif Hiehllehfc
<br />Group Name: Mayfield Vlllage
<br />Group Number: TBD
<br />Effective Date: January 1, 2019
<br />For Existina Business Sold Prior to 1?1 2p?
<br />Prepared By: Andrea D. Knierim
<br />Date Submitted: 111912018
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<br />Deductibie (Applles to Retail & Mail Ortler) ? Y ..k???Jr 7 Q"4 ??x ?. - ,t S? p ?. ? s.a^ I Y Y^
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<br /> RETAIL 30Da Su f
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<br />Generic Copay '?1\
<br />$5.00 ??`"<r,?;-?tiNx
<br />FormularyCo
<br />pay $25.00 ?s..,.?,.
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<br />MAILORDER 90Da Su I .
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<br />' Formulary Drug Llst orugs on tne formulary Iist wm oe usea.
<br />' Generic inoontive: If a member or physician requesls a brend-name drug and a generiquivalent exists, the member pays the generic capaymenl PLUS the diiference between the cost of the generic and brand-name drug.
<br />' Home Delivary Incentive: When a member chooses to fdl a prescriplion a fourlh time a a retail phartnacy within 180 days, the member w01 pay TWICE the normal retail copaymenl.
<br />Benefils will be delermined Dased on Medical Mutual's medical and administrative palicias and procedures. This document is only a partial listing of benefits. Thls is not a contract of Insurance. No person otber than an officer of Medical Mutual may
<br />agree. orally or in wriling, to change the benefits Iistetl here. The confract ar certiricate will contain the complete listing ot cavered sarvices.
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