Page 14 - 2015 CBRY Enrollment Guide
P. 14
2015 Beneit Guide
Prescription Prescription Drugs
2015 Prescription Drug Beneits
Beneits Retail (30-day supply)
Tier 1 10% with a minimum of $10 copay
Your prescription drug Tier 2 20% with a minimum of $25 copay
benefits are currently Tier 3 20% with a minimum of $40 copay
administered by OptumRx, Tier 4 10% or 20% with a maximum $80 copay
a UMR partner. As a Mail Order (90-day supply)
participant in the ASARCO Tier 1 $20 copay
medical plans, you have Tier 2 $50 copay
two ways to purchase your Tier 3 $80 copay
prescribed medications Prescription Out-of-Pocket Maximum
through OptumRx: HRA Plan $3,600 per individual/$7,200 per family
Mail order PPO Plan $4,350 per individual/$8,700 per family
Your local retail pharmacy
Once you meet the prescription out-of-pocket maximum the plan pays
100% of your prescription expenses.
Pharmacy Quantity Limits
Your pharmacy beneit plan has quantity limits for certain drugs. This
program protects you and can help you get the best results from your
medication therapy.
Quantity limits are based on:
X Food and Drug Administration (FDA) approved indications
X Manufacturer’s package labeling instructions
X Well-accepted or published clinical recommendations
For questions about quantity limits or your pharmacy beneit plan, call
OptumRx at (877) 559-2955.
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Prescription Prescription Drugs
2015 Prescription Drug Beneits
Beneits Retail (30-day supply)
Tier 1 10% with a minimum of $10 copay
Your prescription drug Tier 2 20% with a minimum of $25 copay
benefits are currently Tier 3 20% with a minimum of $40 copay
administered by OptumRx, Tier 4 10% or 20% with a maximum $80 copay
a UMR partner. As a Mail Order (90-day supply)
participant in the ASARCO Tier 1 $20 copay
medical plans, you have Tier 2 $50 copay
two ways to purchase your Tier 3 $80 copay
prescribed medications Prescription Out-of-Pocket Maximum
through OptumRx: HRA Plan $3,600 per individual/$7,200 per family
Mail order PPO Plan $4,350 per individual/$8,700 per family
Your local retail pharmacy
Once you meet the prescription out-of-pocket maximum the plan pays
100% of your prescription expenses.
Pharmacy Quantity Limits
Your pharmacy beneit plan has quantity limits for certain drugs. This
program protects you and can help you get the best results from your
medication therapy.
Quantity limits are based on:
X Food and Drug Administration (FDA) approved indications
X Manufacturer’s package labeling instructions
X Well-accepted or published clinical recommendations
For questions about quantity limits or your pharmacy beneit plan, call
OptumRx at (877) 559-2955.
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