Highlights of the Plan
Coverage Tier | In-Network* Benefit | Out-of-Network Benefit |
| Approved Over-the-Counter Drugs and Health Center Drugs | You pay $0 when prescribed and dispensed at an on-site Health Center | Not covered |
| Approved Preventive | You pay $0 (certain drugs covered only when dispensed at an on-site Health Center) | You pay in full when you obtain the drugs. You then file a claim to be reimbursed for the amount the Plan would have paid to an In-Network pharmacy (in other words, the EnvisionRxOptions-discounted amount less your coinsurance) |
| Approved Disease-Management | You pay $5 copay | |
| Generic Preferred Drugs | You pay $5 copay (some $0 copay exceptions noted in the Covered Medication Search | |
| Generic Non-Preferred Drugs | You pay 10% ($10 minimum coinsurance) | |
| Brand-Name Preferred Drugs | You pay 20% ($10 minimum coinsurance) | |
| Brand-Name Non-Preferred Drugs | You pay 40% ($10 minimum coinsurance) | |
| Specialty Drugs | See "Specialty Drugs" |
| Other Highlights | In-Network* Benefit | Out-of-Network Benefit | |
|---|---|---|---|
| Deductible | None; you do not need to satisfy an annual deductible before the Plan pays expenses for the calendar year | None | |
| Annual Out-of-Pocket Limit | Included in the combined medical/prescription out-of-pocket limit of $7,900 person/$15,800 family for eligible medical and prescription drug expenses (these amounts generally are adjusted each year by the federal government) | None | |
| Drug Supply per Prescription |
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| Cost of Coverage (Employee Premium) | No cost to you; your employer provides this coverage without requiring employees to pay a premium | ||
| How to Reach Customer Service |
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* Includes more than 60,000 retail pharmacies that participate in the EnvisionRxOptions network, and includes the EnvisonMail mail-order pharmacy.
Step-therapy (ST) requirements, prior-authorization (PA) requirements, generic-substitution requirements, Care Coordination requirements, quantity limits (QL), other limits or requirements, and/or exclusions apply for certain drugs. For details, review the full Prescription Drug Plan section of this handbook and refer to Covered Medication Search; for additional information call EnvisionRxOptions Customer Service at (800) 361-4542. In-Network pharmacists always have access to up-to-date information in the Envision claims system, to ensure they can inform you of your share of the cost before you complete any purchases.
