Page 7 - 2018 CareHere Enrollment OOS

CareHere

Prescription Drugs

The participating pharmacy network includes large drug store chains
such as Walgreens and CVS, as well as many independent pharmacies.
Your copayment for preventive prescriptions vary depending on the type
of drug used to ill your prescription. Non-preventive prescriptions are
subject to the calendar year deductible and out-of-pocket maximum.

Provided by SAV-RX
Prescription Drugs*
Retail 30-Day Supply
Generic $5 copay preventive Rx; all other—20%
after deductible
Preferred Brand $25 copay preventive Rx; all other—20%
after deductible
Non-Preferred Brand $50 copay preventive Rx; all other—20%
after deductible
Mail Order 90-Day Supply
Generic $5 copay per 30 day supply preventive
Rx; all other Rx—20% after deductible
Preferred Brand $25 copay per30 day supply preventive
Rx; all other Rx—20% after deductible
Non-Preferred Brand $50 copay per 30 day supply preventive
Rx; all other Rx—20% after deductible

* If you select a brand name drug when a generic equivalent is available, the plan will only pay
the cost of the generic drug.

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