Page 17 - 2021-2022 New Hire Benefits

Mail Order Pharmacy
(up to a 90 day supply per In-network member pays
prescription)

Non-preferred brand drugs $80 copayment/prescription
(Tier 3) after bene t deductible

Getting care outside of our network
• Your plan does not cover services rendered outside of our network

Additional Information
• Under this program covered prescription drugs and supplies are put into categories (i.e., tiers) to
designate how they are to be covered and the member's cost-share. The placement of a drug or
supply into one of the tiers is determined by the ConnectiCare Pharmacy Services Department and
approved by the ConnectiCare Pharmacy & Therapeutics Committee based on the drug's or
supply's clinical e ectiveness and cost, not on whether it is a generic drug or supply or brand name
drug or supply.
• Most specialty drugs are dispensed through specialty pharmacies by mail, up to a 30 day supply.
Specialty pharmacies have the same member cost share as all other participating pharmacies and are
not part of ConnectiCare's voluntary mail order program. The member cost share for specialty
pharmacy is di erent from the cost share for ConnectiCare's mail order program.
• If you are a Massachusetts resident, please refer to your amendatory rider for Massachusetts
mandated bene ts for additional details of your bene ts.

CCI/HMO/BS LG (01/2021) E ective Date: 7/2021
Choice_HMO-OA-129630
CT H00154139 / MA H01254140 -129630
Choice HMO-OA-CNT-30-45-300-500D-01
Bene t ID: Lk