Page 8 - 2019-2020 Country Financial Credit Union Benefit Booklet

Prescription Drug Plan Summary

Introducing…Southern Scripts! An added value of using Bywater is their
partnership with a pharmacy benefit manager (or PBM). A PBM manages your
pharmacy benefits to ensure you are receiving the best deal on prescriptions

with the best outcomes. Any pharmacy related questions should be directed
to the experts at Southern Scripts by calling (800) 710.9341 or visiting their
website at www.southernscripts.net/members.php.
Please refer to the Benefits Summary for limitations and exclusions.

Southern Scripts
(800) 710.9341 / www.southernscripts.net/members.php

CORE Plan BUY-UP Plan
Group #: TBD Group #: TBD

Tier 1: 30-Day Supply $ 20 Copay $ 15 Copay

Tier 2: 30-Day Supply $ 65 Copay $ 50 Copay

Tier 3: 30-Day Supply $ 100 Copay $ 75 Copay

Tier 1: 90-Day Supply $ 60 Copay $ 37.50 Copay

Tier 2: 90-Day Supply $ 195 Copay $ 125 Copay

Tier 3: 90-Day Supply $ 300 Copay $ 187.50 Copay

Note: This is intended to be an easy-to-read summary (not a contract); the above items are only highlights of the plans. Additional limitations and exclusions
may apply to covered services. For a full description of your coverage, please refer to your Certificate of Coverage. In the event of any inconsistencies with the
comparison and the insurer’s Certificate of Coverage, the Certificate will control.
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