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APPENDIX A <br /> MEDICAL City of North Olmsted <br /> MUTUAL,, Prescription Drug Program <br /> [Benefits Co,a I Da Su• •1 <br /> Benefit Period January 151 through December 31st <br /> Dependent Age Limit 26 <br /> Over Aged Child 28 <br /> • <br /> Removal upon End of Month <br /> Formulary Retail Program with Oral Contraceptive Coverage—mandatory mail order after the <br /> second retail fill of a prescription drug _T <br /> Generic Copayment $10 30 <br /> Formulary Copayment $20 30 <br /> Non-Formulary Copayment $30 30 <br /> • <br /> Formulary Home Delivery Program with Oral Contraceptive Coverage <br /> Generic Copayment $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 <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 />