The eligibility and enrollment rules for the U

Retiree Health Care SPD Effective January 1, 2012
Pharmacy Coverage Summary
Early Retiree Medical Option
Combined Pharmacy/Medical
Deductible (non-embedded) per
plan year
Combined Pharmacy/Medical
Out-of-Pocket Maximum (nonembedded)
per plan year
Formulary (Preferred) Drug List
Used
Mail Order Maintenance Drug
Provision Applies
• You pay $2,000 per person (only applies if Individual coverage level
elected)
• You pay $3,000 per Family
• You pay $5,000 per person (only applies if Individual coverage level
elected)
• You pay $7,500 per Family
Yes - See the “Formulary Drugs” section in this SPD for more information.
Yes - See the “Mail Order Maintenance Drug Provision” section in this SPD for
more information.
Diabetic Supply Exception Applies Yes – See the “Diabetic Supply Exception” section in this SPD for more
information.
Specialty Drug Provision Applies Yes - See the “Specialty Drug Provision” section in this SPD for more information.
Mail Order Using the Medco Pharmacy (up to a 90-day supply*) or Accredo (for specialty drugs per each 30-day
supply*)
Preferred Drugs Non-Preferred Drugs
If a generic drug is requested ... You pay $25 copayment per covered prescription.
If a brand-name drug is dispensed
and a generic drug IS available ...
If a brand-name drug is dispensed
and a generic drug IS NOT available
...
You pay 30% coinsurance ($50
minimum, $175 maximum) plus the cost
difference between the brand-name and
generic per covered prescription.
You pay 30% coinsurance ($50
minimum, $175 maximum) per covered
prescription.
You pay 45% coinsurance ($125
minimum, $250 maximum) plus the
cost difference between the brand-name
and generic per covered prescription.
You pay 45% coinsurance ($125
minimum, $250 maximum) per covered
prescription.
Retail Pharmacy (up to a 31-day supply*)
Preferred Drugs Non-Preferred Drugs
If a generic drug is requested at a You pay 20% coinsurance ($10 minimum**, $35 maximum) per covered
participating Retail Pharmacy ... prescription.
If a brand-name drug is dispensed at You pay 30% coinsurance ($20
You pay 45% coinsurance ($50
a participating Retail Pharmacy and minimum**, $175 maximum) plus the minimum**, $250 maximum) plus the
a generic drug IS available ... cost difference between the brand-name
and generic per covered prescription.
cost difference between the brand-name
and generic per covered prescription.
If a brand-name drug is dispensed at You pay 30% coinsurance ($20
You pay 45% coinsurance ($50
a participating Retail Pharmacy and minimum**, $175 maximum) per minimum**, $250 maximum) per covered
a generic drug IS NOT available ... covered prescription.
prescription.
When you use a non-participating You pay 50% coinsurance ($50 minimum**, no maximum) of the allowed amount
Retail Pharmacy ...
per covered prescription. If a brand-name drug is dispensed and a generic drug is
available, you will also pay the cost difference between the brand-name and generic
per covered prescription.
Where applicable, taxes will be added to copayment/coinsurance amounts. In addition, all copayment/coinsurance amounts
are paid after the deductible has been satisfied.
* Additional criteria as noted throughout the “Pharmacy” section in this SPD may apply to determine whether specific
drugs are covered and in what dosage or quantity amount. Please call Medco if you have questions about coverage
and/or limitations on the quantity or dosage amount covered for a specific prescription drug.
** Or the full cost if less than the minimum.
See the section “Glossary of Terms” in this SPD for all definitions and the “Deductibles,
Coinsurance and Maximums” section in this SPD for more information. In addition, refer to the
“What the Options Cover” section in this SPD for information related to covered medical services
under this Program.
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