Page 25 - QCS.19 SPD - PPO

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:
$15 copay

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

For a Tier-3 Prescription Drug Product:
$75 copay
For a Tier-4 Prescription Drug Product:
$250 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:
$38 copay

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

For a Tier-3 Prescription Drug Product:
$188 copay
For a Tier-4 Prescription Drug Product:
$625 copay

Page 20 Section 4 - Schedule of Benefits
PPO - 2017