Page 7 - 2018 Sulzer (Pumps Solutions) Benefit Guide
P. 7
Sulzer
Prescription Drugs
The prescription drug plan is administered by Express Scripts Pharmacy.
The prescription drug plan is limited to in-network beneits only. The
participating pharmacy network includes large drug store chains such as
Walgreens and CVS, as well as many independent pharmacies.
Express Scripts
HDHP 2500 PPO 1500
In-Network In-Network
Prescription Drugs
Deductible Medical deductible None
applies
Step Therapy Applies Applies
Retail—Up to a 90-Day Supply
Tier 1—Generic 85% after ded $15 copay
Tier 2—Preferred Brand 85% after ded $30 copay
Tier 3—Non-Preferred Brand 85% after ded $55 copay
Mail Order—Up to a 90-Day Supply
Tier 1—Generic 85% after ded $30 copay per 90 day
supply
Tier 2—Preferred Brand 85% after ded $60 copay per 90 day
supply
Tier 3—Non-Preferred Brand 85% after ded $110 copay per 90 day
supply
Medications are limited to those included on Express Scripts National
Preferred TClass drug formulary; visit www.express-scripts.com/
NATPLSNATPREF14.
If you choose to take a brand name drug when a generic equivalent is
available, the plan will only cover the cost of the generic drug. If your
physician has indicated the drug should be dispensed as written, the plan
will pay the cost of the brand name drug.
Specialty medications are limited to a 30-day supply and must be illed
through Accredo Pharmacy, the Express Scripts specialty pharmacy. The
initial ill of a specialty medication may be obtained at a retail pharmacy.
Certain prescriptions may require prior authorization, require the use of
a lower-cost therapeutic equivalent, and/or have quantity limits. Contact
the Express Scripts member services number at the back of this guide for
further details.
7
Prescription Drugs
The prescription drug plan is administered by Express Scripts Pharmacy.
The prescription drug plan is limited to in-network beneits only. The
participating pharmacy network includes large drug store chains such as
Walgreens and CVS, as well as many independent pharmacies.
Express Scripts
HDHP 2500 PPO 1500
In-Network In-Network
Prescription Drugs
Deductible Medical deductible None
applies
Step Therapy Applies Applies
Retail—Up to a 90-Day Supply
Tier 1—Generic 85% after ded $15 copay
Tier 2—Preferred Brand 85% after ded $30 copay
Tier 3—Non-Preferred Brand 85% after ded $55 copay
Mail Order—Up to a 90-Day Supply
Tier 1—Generic 85% after ded $30 copay per 90 day
supply
Tier 2—Preferred Brand 85% after ded $60 copay per 90 day
supply
Tier 3—Non-Preferred Brand 85% after ded $110 copay per 90 day
supply
Medications are limited to those included on Express Scripts National
Preferred TClass drug formulary; visit www.express-scripts.com/
NATPLSNATPREF14.
If you choose to take a brand name drug when a generic equivalent is
available, the plan will only cover the cost of the generic drug. If your
physician has indicated the drug should be dispensed as written, the plan
will pay the cost of the brand name drug.
Specialty medications are limited to a 30-day supply and must be illed
through Accredo Pharmacy, the Express Scripts specialty pharmacy. The
initial ill of a specialty medication may be obtained at a retail pharmacy.
Certain prescriptions may require prior authorization, require the use of
a lower-cost therapeutic equivalent, and/or have quantity limits. Contact
the Express Scripts member services number at the back of this guide for
further details.
7
