Caring For Those Who Serve
1201 Davis Street Evanston, Illinois 60201-4118
2010 Medco Pharmacy Fixed Co-Payment Plan 1 — FX 1
Administered by Medco: 1-800-841-2806 www.gbophb.org Plan Feature Retail Pharmacy Benefit Medco by Mail (Mail-Order) Benefit Annual Deductible
Family Annual Out-of-Pocket (OOP) Maximum1, 2 Generic Drugs (Tier 1) Preferred Brand-Name Drugs $15 co-payment after the deductible Non-Preferred Brand-Name Drugs (Tier 3) Prescription Non-Sedating Antihistamine Drugs (e.g., Zyrtec, Allegra and Clarinex) Retail Refill Allowance (RRA) Participants will be allowed to obtain three fills of maintenance medication at the
retail pharmacy. For all subsequent fills at the retail pharmacy, participants will be responsible for paying 100% of the discounted cost. For maximum benefits, refills for most maintenance medications will require fulfillment through the Medco by Mail Pharmacy Program.
1 Excludes charges applied toward the retail pharmacy deductible, co-payments for non-preferred brand-name drugs and additional
costs incurred when a brand-name drug is chosen but a generic version is available.
2 There is one Annual Out-of-Pocket (OOP) Maximum that includes charges incurred through the retail pharmacy and Medco by Mail Additional Information The patient is required to pay the generic co-payment plus the difference in cost between the generic and brand-name drug when the brand-name drug is chosen but a generic version is available. The additional cost does not apply to the annual out-of-pocket maximum. Some medications may be covered by your benefit plan only for certain uses or in certain quantities. For example, a medication may not be covered when it is used for cosmetic purposes or a quantity may be limited to certain amounts over certain time periods. Contact Medco at 1-800-841-2806 if you have any questions. If you purchase a prescription without using your card, you will need to complete a Prescription Drug Reimbursement Claim Form. You can obtain the form by visiting www.medco.com or by dialing 1-800-841-2806 to speak to a customer service representative. Prescriptions purchased at a non-participating pharmacy are processed as out of network and may be subject to a higher co-payment reimbursement rate. Any difference between the amount submitted (retail cost) and the amount approved is not reimbursable. The reimbursement rate is also determined after the deductible and co-payments are subtracted.
This summary highlights some of the features of this benefit plan. The summary is for illustrative purposes only and is subject
to change at any time. The controlling terms and conditions of the benefit plan are contained in the Plan Document, the Summary
Plan Description and the HealthFlex Benefit Booklet (collectively, the “Documents”) maintained by the General Board of Pension and Health Benefits. If there are any conflicts between this summary and the terms of the Documents, the terms of the Documents
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