Page 11 - 2015 DAN Benefits Guide
P. 11
Dentsu Aegis Network (DAN)
Pharmacy Plan Highlights
Standard Plan Enhanced Plan Premium Plan Health Savings Plan **** HMO (CA
Only)
Plan Out-of- Out-of- Out-of- Out-of- HMO
Feature* In-Network Network In-Network Network In-Network Network In-Network Network Network
Prescripion Drug Program
Retail Pharmacy ***
Generic $10 copay $10 copay $10 copay Ded. and Coin. $10 copay
Brand Name $30 copay $30 copay $30 copay Ded. and Coin.
Formula
Brand $50 copay $50 copay $50 copay Ded. and Coin. $30 copay
name Non-
Formulary
Mail Order ***
Generic $20 copay $20 copay $20 copay Ded. and Coin. $20 copay
Brand Name $60 copay $60 copay $60 copay Ded. and Coin.
Formula
Brand $100 copay $100 copay $100 copay Ded. and Coin. $60 copay
name Non-
Formulary
* In-network beneits relect the negoiated fees charged by network providers. Out-of-network beneits are subject to R&C (reasonable and customary) limits.
** Copays and coinsurance under the in-network porion of a medical opion and the prescripion drug program will apply towards the medical out-of-pocket
maximum as required by healthcare reform legislaion.
*** For retail out of network pharmacy expenses you will be responsible for the diference between the Predominant Reimbursement Rate and a Network
Pharmacy’s Usual and Customary Charge (which includes a dispensing fee and sales tax) for that Prescripion Drug Product. Mail order out of network pharmacy
expenses are not covered.
**** The H.S.A. PPO features a non-embedded deducible and out-of-pocket maximum; if you cover one or more dependents the full family deducible must be
saisied by one or more family members before cost sharing (coinsurance) begins and the full family out-of-pocket maximum must be saisied by one or more
family members before the plan begins covering 100% of eligible expenses during the plan year.
11
Pharmacy Plan Highlights
Standard Plan Enhanced Plan Premium Plan Health Savings Plan **** HMO (CA
Only)
Plan Out-of- Out-of- Out-of- Out-of- HMO
Feature* In-Network Network In-Network Network In-Network Network In-Network Network Network
Prescripion Drug Program
Retail Pharmacy ***
Generic $10 copay $10 copay $10 copay Ded. and Coin. $10 copay
Brand Name $30 copay $30 copay $30 copay Ded. and Coin.
Formula
Brand $50 copay $50 copay $50 copay Ded. and Coin. $30 copay
name Non-
Formulary
Mail Order ***
Generic $20 copay $20 copay $20 copay Ded. and Coin. $20 copay
Brand Name $60 copay $60 copay $60 copay Ded. and Coin.
Formula
Brand $100 copay $100 copay $100 copay Ded. and Coin. $60 copay
name Non-
Formulary
* In-network beneits relect the negoiated fees charged by network providers. Out-of-network beneits are subject to R&C (reasonable and customary) limits.
** Copays and coinsurance under the in-network porion of a medical opion and the prescripion drug program will apply towards the medical out-of-pocket
maximum as required by healthcare reform legislaion.
*** For retail out of network pharmacy expenses you will be responsible for the diference between the Predominant Reimbursement Rate and a Network
Pharmacy’s Usual and Customary Charge (which includes a dispensing fee and sales tax) for that Prescripion Drug Product. Mail order out of network pharmacy
expenses are not covered.
**** The H.S.A. PPO features a non-embedded deducible and out-of-pocket maximum; if you cover one or more dependents the full family deducible must be
saisied by one or more family members before cost sharing (coinsurance) begins and the full family out-of-pocket maximum must be saisied by one or more
family members before the plan begins covering 100% of eligible expenses during the plan year.
11
