Page 104 - Cover Letter and Evaluation for Patricia Hendrickson
P. 104
Pharmacy
If you need drugs to Generic drugs Retail: $15 co-pay Mail Coverage is limited up to a 30-day
treat your illness or condition. Order: $30 co-pay supply (retail) and up to a 90-day
supply (mail order).
The plan uses a preferred drug Retail: $40 co-pay Mail Coverage is limited up to a 30-day
list, which identifies the status of Preferred brand drugs Order: $80 co-pay supply (retail) and up to a 90-day
covered drugs. Rules and supply (mail order).
restrictions, such as prior
authorization requirements, are in Non-preferred brand drugs Retail: $60 co-pay Mail Coverage is limited up to a 30-day
place for accessing certain types Order: $120 co-pay supply (retail) and up to a 90-day
of specialty drugs and supply (mail order).
medications. Prescription drug
coverage is provided through Specialty drugs 25% up to $200
Express Scripts; for more maximum
information go to
www.express-scripts.com.
Prescription Drug
Calendar Year Out-of-Pocket
Maximum $2,000 per covered individual
1/1/2017
ASO
Comprehensive Indemnity - Comprehensive - Indemnity Medicare Plan - Retirees Over 65 - 5295897. Version# 6
10 of 10 ©Cigna 2016
