Page 5 - 2020AONBenefitGuide
P. 5
Pharmacy Benefits
Beneit Highlights PPO High Deductible Health Plan with HSA
In-Network Out-of-Network In-Network Out-of-Network
Prescription Drugs—Retail (per 30-day supply)
Preferred Generic Prescription Drugs $10 copay 50% $10 copay after in- 50% after in-network
network deductible
deductible
Preferred Brand Name Prescription Drugs $50 copay 50% $50 copay after in- 50% after in-network
deductible
network deductible
Non-Preferred Prescription Drugs $80 copay 50% $80 copay after in- 50% after in-network
deductible
network deductible
Oral Chemotherapy Drugs $10 copay 50% $10 copay after in- 50% after in-network
network deductible
deductible
Mail Order (90-day supply)
Preferred Generic Prescription Drugs $25 copay $25 after in-network deductible
Preferred Brand Name Prescription Drugs $125 copay $125 after in-network deductible
Non-Preferred Prescription Drugs $200 copay $200 after in-network deductible
Oral Chemotherapy Drugs $25 copay $25 after in-network deductible
Retail Pharmacy Maintenance Medications
Prime Therapeutics is our pharmacy beneit manager. Maintenance medications are
prescriptions used to treat conditions
Members can utilize any of the more than 60,000 pharmacies in the that are considered chronic or
network to pick up your 30-day supply prescriptions, such as antibiotics long-term. These medications treat
as prescribed by your doctor, except those considered maintenance ongoing conditions or needs. A
medications. Your medical ID card also has your prescription plan few examples that are commonly
information on it. You will not receive a separate card for prescriptions. considered to be maintenance
medications are asthma, diabetes,
Specialty Medications birth control, high cholesterol,
FL Blue utilizes CVS Caremark and AllianceRx Walgreens Prime. high blood pressure, and arthritis.
X If you are currently taking a specialty pharmacy medication, then your Maintenance medication must
be illed at mail order with CVS/
network for specialty pharmacies is limited to: Caremark or AllianceRX Walgreens
Y CVC/Caremark Specialty Pharmacy Services (excludes Prime. You can get a 90-day supply
Hemophilia) on most mail order medications.
Y CVC/Caremark Hemophilia Services
Y AllianceRx Walgreens Prime For additional important
X Examples of specialty mediations include: information on in-
network pharmacy
Y Aminoglycosides (ex: Tobramycin) providers, please see
Y Antivirals (ex: Ribavirin, Harvoni) page 6.
Y Malaria (ex: Daraprim)
American Oncology Network 5
Beneit Highlights PPO High Deductible Health Plan with HSA
In-Network Out-of-Network In-Network Out-of-Network
Prescription Drugs—Retail (per 30-day supply)
Preferred Generic Prescription Drugs $10 copay 50% $10 copay after in- 50% after in-network
network deductible
deductible
Preferred Brand Name Prescription Drugs $50 copay 50% $50 copay after in- 50% after in-network
deductible
network deductible
Non-Preferred Prescription Drugs $80 copay 50% $80 copay after in- 50% after in-network
deductible
network deductible
Oral Chemotherapy Drugs $10 copay 50% $10 copay after in- 50% after in-network
network deductible
deductible
Mail Order (90-day supply)
Preferred Generic Prescription Drugs $25 copay $25 after in-network deductible
Preferred Brand Name Prescription Drugs $125 copay $125 after in-network deductible
Non-Preferred Prescription Drugs $200 copay $200 after in-network deductible
Oral Chemotherapy Drugs $25 copay $25 after in-network deductible
Retail Pharmacy Maintenance Medications
Prime Therapeutics is our pharmacy beneit manager. Maintenance medications are
prescriptions used to treat conditions
Members can utilize any of the more than 60,000 pharmacies in the that are considered chronic or
network to pick up your 30-day supply prescriptions, such as antibiotics long-term. These medications treat
as prescribed by your doctor, except those considered maintenance ongoing conditions or needs. A
medications. Your medical ID card also has your prescription plan few examples that are commonly
information on it. You will not receive a separate card for prescriptions. considered to be maintenance
medications are asthma, diabetes,
Specialty Medications birth control, high cholesterol,
FL Blue utilizes CVS Caremark and AllianceRx Walgreens Prime. high blood pressure, and arthritis.
X If you are currently taking a specialty pharmacy medication, then your Maintenance medication must
be illed at mail order with CVS/
network for specialty pharmacies is limited to: Caremark or AllianceRX Walgreens
Y CVC/Caremark Specialty Pharmacy Services (excludes Prime. You can get a 90-day supply
Hemophilia) on most mail order medications.
Y CVC/Caremark Hemophilia Services
Y AllianceRx Walgreens Prime For additional important
X Examples of specialty mediations include: information on in-
network pharmacy
Y Aminoglycosides (ex: Tobramycin) providers, please see
Y Antivirals (ex: Ribavirin, Harvoni) page 6.
Y Malaria (ex: Daraprim)
American Oncology Network 5
