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City of North Ofmsted <br />??i E D? CA L <br />MUTUAL prescriptiar? Drug Program <br />,? <br />Benefits Copay Day Supply <br />? Benefit Period January 1s1through December 3151 ? <br />Dependent Age Limit 19 Dependent / 25 Student j <br />Removal upon Birfhdate j <br />, Formulary Retail Program with Oral Contraceptive Coverage - mandatory mail drder after the i <br />'second retail fill of a prescriptian drug <br />' Generic Gopayment $10 30 <br />Formulary Copayrnent $20 30 <br />Non-Formulary Copayment $30 30 <br />Formulary Home Delivery Program with Oral Cantraceptive Coverage <br />Generic Copayment $25 90 <br />Formufary Copayrnent $50 90 <br />Non-Formulary Copayment ? $75 90 <br />Note: In an effort to continue our cammitment to quatity care and help contain the increasing cost of prescription <br />drug coverage, a formulary feature is included in yaur prescription drug benefit. A formulary drug is a FDA <br />approved prescription medication reviewed by an independent Pharmacy and Therapeutics Committee <br />brought together by Medco Health Solutions, Inc. Formulary drugs can assist in maintaining quafity care while <br />meeting your plan's cost containment objectives. <br />Benefits will be determined based on Medicai Mutual's medical and administrative policies and procedures. <br />This document is only a partial listing Qf benefits. This is not a contract of insurance. No person other than an <br />afficer of Metlical Mutual may agree, orally or in writing, to change the benefits listed here. The contract or <br />certificate wiU contain the complete listirrg of covered services. <br />1112