Health Pool  Pharmacy Program

Prescription Drug Benefit Summary:

• No Calendar Year Benefit Limit

• $200 Annual Deductible for Plans I, II & III

• $500 Annual Deductible for Plan IV

• $1,250 Annual Deductible for HSA-Qualified Plan V
   

 I.  Retail Pharmacy Copays (up to a 30-day supply)

• Generics......................$10

• Formulary Brands.........$25 (plus cost difference if generic available)

• Non-Formulary Brands..$40 or 50% of the cost of the drug, whichever is greater
                                     (plus cost difference if generic available)

 II.  Medco Mail Order Pharmacy Copays (up to 90-day supply.

• Generics...................... $25 

• Formulary Brands......... $60 (plus cost difference if generic available)

• Non-Formulary Brands...$100 or 50% of the cost of the drug, whichever is greate
                                      (plus the cost difference if generic is available)

 III.  Specialty Medication Medication Copays:  $100  (30-day supply)

• Specialty Medications are prescription drugs that cost $500 or more per dose, or $6,000 or more per year,* and have one or more of the following characteristics:

• Certain specialty medications are covered by the Pool only when they are provided through the Pool’s pharmacy benefit, by Medco/Accredo.  These medications consist of all hemophilia factor and growth hormone medications, as well certain other infused drugs.  Click on the link below for a list of these restricted infused drugs:

  Specialty Infused Medications Dispensed Only Through Pharmacy Benefit

   

 NOTES:

• The outpatient prescription drug benefit is not available to a Pool enrollee who is also eligible for Medicare.

•  $1,500 annual cap on copayments for HSA-Qualified Plan V.