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Benefit Information

            Prescription Drugs from a Retail Network Pharmacy

            The following supply limits apply:
               ·   As written by the provider, up to a consecutive 30-day supply of a Prescription Drug Product, unless
                   adjusted based on the drug manufacturer's packaging size, or based on supply limits.
               ·   When a Prescription Drug Product is packaged or designed to deliver in a manner that provides more
                   than a consecutive 30-day supply, the Copayment, Annual Deductible, and/or Coinsurance that applies
                   will reflect the number of days dispensed.

            Your Copayment, Annual Deductible, and/or Coinsurance is determined by the tier to which the Prescription Drug
            List Management Committee has assigned the Prescription Drug Product. All Prescription Drug Products on the
            Prescription Drug List are assigned to Tier-1, Tier-2, Tier-3, or Tier-4. Please contact us at www.my.allsavers.com
            or the telephone number on your ID card to determine tier status.
            For a Tier-1 Prescription Drug Product:
            deductible then $10 copay

            For a Tier-2 Prescription Drug Product:
            deductible then $35 copay

            For a Tier-3 Prescription Drug Product:
            deductible then $60 copay
            For a Tier-4 Prescription Drug Product:
            deductible then $100 copay

            Prescription Drug Products from a Mail Order Network Pharmacy

            The following supply limits apply:
               ·   As written by the provider, up to a consecutive 90-day supply of a Prescription Drug Product, unless
                   adjusted based on the drug manufacturer's packaging size, or based on supply limits.
               ·   You may be required to fill the first Prescription Drug Product order and get 1-3 refills through a retail
                   pharmacy using a mail order Network Pharmacy.

            To maximize your Benefit, ask your Physician to write your Prescription Order or Refill for a 90-day supply, with
            refills when appropriate. You will be charged a mail order Copayment, Annual Deductible, and/or Coinsurance for
            any Prescription Orders or Refills sent to the mail order pharmacy regardless of the number-of-days' supply
            written on the Prescription Order or Refill. Be sure your Physician writes your Prescription Order or Refill for a 90-
            day supply, not a 30-day supply with three refills.
            Your Copayment, Annual Deductible, and/or Coinsurance is determined by the tier to which the Prescription Drug
            List Management Committee has assigned the Prescription Drug Product. All Prescription Drug Products on the
            Prescription Drug List are assigned to Tier-1, Tier-2, Tier-3, or Tier-4. Please contact us at www.my.allsavers.com
            or the telephone number on your ID card to determine tier status.

            The mail order Copayment for up to a 90-day supply is:
            For a Tier-1 Prescription Drug Product:
            deductible then $25 copay

            For a Tier-2 Prescription Drug Product:
            deductible then $88 copay

            For a Tier-3 Prescription Drug Product:
            deductible then $150 copay
            For a Tier-4 Prescription Drug Product:
            deductible then $250 copay





            Page 20                                                                      Section 4 - Schedule of Benefits
                                                                                                       HSA - 2017
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