Laserfiche WebLink
<br />City of P~orth Q~irnsted <br />J~~ L= D I CA L Prescription Dreg Program <br />l~~t U T U h L,~ <br />Benefits Copay Day Supply <br />Benefit Period <br />January 1s1 through December 315` ~, <br />Dependent Age Limit 19 Dependent / 25 Student ', <br />P.emoval upon Bii~thdate <br />Formulary Retail Program with Oral Contraceptive Coverage -mandatory mail order after the <br />second retail fill of a prescription drug __ __i <br />Generic Copayment $10 30 _~ <br />Formulary Copayment X20 30 <br />fvon-Formulary Copayment $30 30 <br />i <br />Formulary Home Delivery Program with Oral Contraceptive Coverage <br />Generic Co a ment <br />p Y $25 90 <br />Formulary Copayment $50 90 <br />Non-Formulary Copayment $75 90 <br />Note; In an effort to continue our commitment to quality care and help contain the increasing cost of prescription <br />drug coverage, a formulary feature is included in your 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 quality care while <br />meeting your plan's cost containment objectives. <br />Benefits will be determined based on Medical Mutual's medical and administrative policies and procedures. <br />This document is only a partial listing of benefits. This is not a contract of insurance. No person other than an <br />officer of Medical Mutual may agree, orally or in writing, to change the benefits listed here. The contract or <br />certificate will contain the complete listing of covered services. <br />Ftf~ctive' 1/1 /OS <br />