Page 5 - The Polyclinic New Hire Guide
P. 5
Pharmacy Coverage Administered by ClearScript
Retail Specialty Pharmacy Mail Order
Supply limit 30 days 30 days 90 days
Tier 1 (generic drugs) $15 copay $50 copay $35 copay
(after deductible) (after deductible) (after deductible)
Tier 2 (preferred brand $40 copay $75 copay $95 copay
drugs) (after deductible) (after deductible) (after deductible)
Tier 3 (non-preferred $60 copay $100 copay $150 copay
brand drugs) (after deductible) (after deductible) (after deductible)
How to Locate a Provider You may elect medical coverage for
X First Choice Health Network (Washington, Alaska, Oregon, Idaho, eligible dependent children and a
lawful spouse. The Polyclinic does not
Montana, Wyoming, North Dakota, South Dakota) offer medical or dental coverage for a
800.231.6935 spouse who is eligible for other medical
www.fchn.com or dental coverage through another
X First Health Network (all other states not served by FCHN) creditable coverage plan. To enroll an
eligible spouse, you must submit the
800.226.5116 Spousal Afidavit found on page 23.
www.irsthealthcoventryhealthcare.com
5
Retail Specialty Pharmacy Mail Order
Supply limit 30 days 30 days 90 days
Tier 1 (generic drugs) $15 copay $50 copay $35 copay
(after deductible) (after deductible) (after deductible)
Tier 2 (preferred brand $40 copay $75 copay $95 copay
drugs) (after deductible) (after deductible) (after deductible)
Tier 3 (non-preferred $60 copay $100 copay $150 copay
brand drugs) (after deductible) (after deductible) (after deductible)
How to Locate a Provider You may elect medical coverage for
X First Choice Health Network (Washington, Alaska, Oregon, Idaho, eligible dependent children and a
lawful spouse. The Polyclinic does not
Montana, Wyoming, North Dakota, South Dakota) offer medical or dental coverage for a
800.231.6935 spouse who is eligible for other medical
www.fchn.com or dental coverage through another
X First Health Network (all other states not served by FCHN) creditable coverage plan. To enroll an
eligible spouse, you must submit the
800.226.5116 Spousal Afidavit found on page 23.
www.irsthealthcoventryhealthcare.com
5
