Laserfiche WebLink
,~ C~t~i a. f`~Jorth O~(fr~sted <br />~, hh L- D I ~' 1', L <br />i-.- pCUs Cf"IE:7ilOF1 ~Cl<g PI"U~Sf"aF1'1 <br />Iii (~ i ~.J f~, L, ' <br />_ _ __ ( ~ <br />je <br />e~tit Copay Day Sup~l <br />~~ ~ <br />~ <br />eeneflt Period <br />~ Dependent Age Liir~it I January 15'through December 31 <br />19 Dependent / 25 Student <br />Removal upon eirtl,date 5 <br />' <br />__ <br />_ <br />Formulary Retail Progra-r~ with Oral Contraceptive Coverage -mandatory mail order after the <br />second retail fill of a prescription drug <br />Generic Copayment 510 30 <br />Formulary Copayment $20 30 - <br />Jon-Foniiulary Copayment $30 3Ci <br />Formulary Hame Delivery Program with Oral C ontraceptive Coverage <br />Generic Copaylr~ent $25 90 <br />Formulary Copayment $50 9D <br />Non-Formulary Copayment $%5 9D <br />Note: In an effort to continue our commitment to quality care ar~d help contain the increasing cost of prescription <br />drug coverage, a formulary feature is included in your prescription drug benefit. P, formulary drug is a FDH <br />approved prescription medication revievded 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 ptar~'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 IMedical (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 />