Health Pool  Pharmacy Program

Prescription Drug Benefit Summary:
(Effective 01/01/2008)

• No Calendar Year Benefit Limit

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

• $500 Annual Deductible for Plan IV
   

 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.  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 greater
                                      (plus the cost difference if generic is available)

 III.  Specialty Medications:  $100 

• Specialty Medications means a prescription drug for which the annual cost is $6,000 or more and for which one or more of the following is required: specialized patient training and coordination of care (services, supplies or devices) prior to therapy initiation and during therapy; unique requirements for patient compliance and safety monitoring; unique requirements for handling, shipping and storage of the drug; or potential for significant waste of high-cost product. 

Specialty drug list link:

Specialty Medications

Note:  The outpatient prescription drug benefit does not apply to an Insured Person eligible for
          Medicare.