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Appendix A <br />City of North Olmsted <br />MEDICAL <br />Ir &� MUTUAL, Prescription Drug Program <br />Benefits <br />Co pay <br />Day Supply <br />Benefit Period January 1S'through December 31St <br />Dependent Age Limit 26 <br />Over Aged Child 28 <br />—� Removal upon End of Month <br />__ <br />Formulary Retail Program with Oral Contraceptive Coverage – mandatory mail order after the —� <br />second retail fill of a prescription drug j <br />Generic Copayment <br />$10 <br />30 <br />_ <br />_ <br />Formulary Copayment <br />$20 <br />30 <br />Non - Formulary Copayment <br />$30 <br />30 <br />Formulary Home Delivery Program with Oral Contraceptive Coverage <br />- - -i <br />Generic Copayment <br />$25 <br />90 <br />Formulary Copayment <br />$50 <br />90 <br />Non- Formulary Copayment <br />$75 j <br />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 <br />FDA approved prescription medication reviewed by an independent Pharmacy and Therapeutics <br />Committee brought together by Medco Health Solutions, Inc. Formulary drugs can assist in maintaining <br />quality care while meeting your plan's cost containment objectives. <br />Benefits will be determined based on Medical Mutual's medical and administrative policies and <br />procedures. <br />This document is only a partial listing of benefits. This is not a contract of insurance. No person other <br />than an officer of Medical Mutual may agree, orally or in writing, to change the benefits listed here. The <br />contract or certificate will contain the complete listing of covered services. <br />1/1/11 <br />