Prescription
Drug Program
Options
A – D, HDHP and
HMO
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Options
A - D
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Contact
Express Scripts toll-free: 800-789-7488 |
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| Acute/Short
Term Therapy Drugs Purchased at a Local Pharmacy: |
Member
copays: |
- Supply
of 30 days or less
- Limited
to four 30-day fills of same prescription * (some
exceptions may apply)
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- Generic,
$10
- Brand-name
formulary, $25
- Non-formulary**,
$45
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Maintenance/Long-Term
Drugs
Express Scripts Mail Order Service: |
Member
copays: |
- Supply
of 31 days or more
- Up
to 90-day supply
- Unlimited
refills as prescribed by your physician
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- Generic,
$15
- Brand-name
formulary, $45
- Non-formulary**,
$80
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Maintenance/Long-Term
Drugs
Purchased at local pharmacy: |
Member
copays: |
- Supply
of 31 days or more up to 90-day supply
- Supply
of 30 days or less, starting after 4th fill
- Unlimited
refills as prescribed by your physician
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- Generic,
$10 or 50% of cost, whichever is greater
- Brand-name
formulary, $45 or 50% of cost, whichever is greater
- Non-formulary**,
$80 or 50% of cost, whichever is greater
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*
After four consecutive fills of the same prescription at
your local pharmacy, starting with the fifth fill, you will
pay 50% of cost, or the appropriate mail order copay for
long-term therapy drugs, whichever is greater. |
| ** A
formulary is a list of prescription medications chosen by
Express Scripts for their ability to be clinically efficient
and cost effective. |
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Options
HDHP
HSA-Compatible High deductible Health Plan (HDHP)
BlueCard Preferred Provider Organization (PPO)
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Contact
Express Scripts toll-free: 800-789-7488 |
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| Network
Benefit Member Pays: |
Non-Network
Benefits Member Pays: |
| 0%
after deductible |
20%
after deductible |
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| Note:
The medical benefit information listed below applies only
for Option HMO in Southern California. To find out if an HMO
option is available in your area, please contact Concordia
Plan Services toll-free: 888-927-7526 |
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(In-Network)*
HMO-California Only Member Pays: |
(In-Network)*
HMO-Select Areas Member Pays |
Prescription
Drugs Purchased At a Participating Retail Pharmacy
(typically for acute/short-term drugs, up to 30-day
supply per prescription) |
Member
copays:
- Generic,
$10
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Brand-name formulary: $20
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Non-preferred, $35
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Member
copays:
(on 1st 4 fills of prescription**)
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Generic, $10
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Brand-name formulary, $20
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Non-preferred, $40
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Prescription
Drugs Purchased Through CIGNA’s Mail Order Drug
Program (Tel-Drug)
(typically for maintenance/long-term
drugs, up to 90-day supply per prescription) |
Member
copays:
- Generic,
$20
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Brand-name formulary: $40
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Non-preferred, $70
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Member
copays:
- Generic,
$20
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Brand-name formulary: $40
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Non-preferred, $80
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| * Prescription
drugs purchased at non-participating pharmacies are the responsibility
of the member. |
| ** After
four consecutive fills of the same prescription at a local
participating pharmacy, starting with the fifth fill the member
will pay 50% of the cost or the appropriate mail order copay,
whichever is greater. |
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