PPO Blue Plan: Prescription Coverage - Teamsters

2017 PPO Blue Prescription Coverage Chart for Teamsters
Deductible None
Total Prescription Drug Out-of-Pocket Maximum (Individual/Family) $1,000/$6,000

Prescription Drug Program

Mandatory Generic

Defined by the National pharmacy network - NOT Physician Network. Prescriptions filled at a non-network pharmacy are not covered

Plan uses the Comprehensive Formulary.

*Retail and Mail Service Pharmacy includes University Health Services Pharmacy

Retail Drugs (31-day supply)*
Member pays 50% per generic
Member pays 50% per formulary brand
Member pays 70% per non-formulary brand

Maintenance Drugs Mail Order (90-day supply)*
Member pays 20% per generic
Member pays 20% per formulary brand
Member pays 70% per non-formulary brand
Specialty Medications
Walgreens Specialty Pharmacy Only
Specialty Medication Formulary

Retail Drugs (31-day supply)
Member pays 50% for Formulary Medications with a $50 maximum member paymet per prescription
Member pays 70% for Formulary Medications with a $100 maximum member paymet per prescription