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Prescription – Rx
Medical Insurance
To Fit Your Needs
The administrator of the Prescription Drug plan is
CVS Caremark. The Prescription Plan’s network
of participating pharmacies is nationwide. The
Prescription Drug plan is imbedded into your
medical insurance and cannot be selected on its
own.
Deductibles, per plan year –
GOLD, SILVER, and BRONZE
Deductible, per plan year, Individual
$50
Deductible, per plan year, Family
$50
GOLD - Copay per Prescription
Retail
30-day supply
Mail Order
90-day supply
Generic
$10
$20
Preferred Brand
$20
$40
Non-Preferred Brand
$35
$70
SILVER and BRONZE - Copay per Prescription
Retail
30-day supply
Mail Order
90-day supply
Generic
$15
$30
Preferred Brand
$25
$50
Non-Preferred Brand
$40
$80
How can you
save
money?
Ask for
Generics
Mail Order
90-day
supply
Use the
Preferred
Pharmacy
network
This summary is intended as a guide to the coverage provided, for a complete description of the coverage terms and limitations
please refer to the Summary Plan Description. In case of a discrepancy, the Summary Plan Description will govern.
Visit
www.caremark.comor call Customer Care
at 1-800-552-8159.