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...,. ~..~.:.~.:~.,~........ll~_~a_ _ _..... wu,~µ .. _ <br /> <br />BBrlefltS <br />Benefit Period <br />Dependent P,ge Linlii <br />CI'Cj~ OI` ~~iOi~L~1 ~I'Ir"1',SZc'G <br />Frescrip~ion Drug r I°ograr~~ <br />COpa. <br />^a~~ ~Lippi <br />January 1s1 through Gecen~ll_,er ~'i51 <br />1 S' Der,endeni / :'.5 ~tudeni <br />F~:,'Ii10Vai U~?ol"1 (JII"ti"1ddtG~ <br />Formulary F~etail Progrull with Oral Gantraceptive Coverage -mandatory I~"lail order after the <br />second retail fill of a prescription dr~.lg .___.. ------- -- <br />- I c a n -~----- :~ D <br />Generic Copayment "" ~ ~' --- <br />~;20 30 <br />Formulary CopaylTlent a0 <br />X30 ; <br />Non-Forl-nuiary Copaylllent <br />Formulary Home Delivery Program with Oral Contraceptive Coverage , J <br />Generic Copayment I $25 <br />X50 9D <br />Formulary Copayment 90 <br />$75 <br />Non-Formulary Copayment <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 />approval 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 IMutual's medical and administrative policies and procedures. <br />This document is only a partial listing of benefits, This is Ijotclla~ne theobenef snl sted herer5 Tit tcontract or <br />officer of IMedical (Mutual may agree, orall} of In wnting, 9 <br />certificate will contain the complete listing of covered services. <br />