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Prescription Drug Summary: Building Trades & Flexible Choice Plans

A Snapshot of Your Coverage

How your plan works. Amounts shown are what you pay per calendar year.

Building Trades Plan

In-Network

HEALTHY LIFE Incentive

In-Network

No Incentive

Out-of-Network
Out-of-Pocket Maximum: Prescription Drug
Individual

$1,650

Not applicable
Family

$8,800

Not applicable
Note: Your in-network and out-of-network eligible expenses cross-apply and accumulate toward your in-network out-of-pocket maximum.

Amounts shown are what you pay at a Sav-Rx participating pharmacy (retail, preferred network retail pharmacy, or mail order).

Program Generic Drugs Preferred Brand Name Drugs Non-Preferred Brand Name Drugs
Retail Program

(up to a 34-day supply)

You pay 10% with a $10 minimum*/$100 maximum copay per initial fill and refill You pay 20% with a $20 minimum*/$100 maximum copay per initial fill and refill You pay 30% with a $40 minimum*/$100 maximum copay per initial fill and refill
Preferred Network Retail Pharmacy

(up to a 90-day supply)

You pay 10% with a $30 minimum*/$300 maximum copay per initial fill and refill You pay 20% with a $60 minimum*/$300 maximum copay per initial fill and refill You pay 30% with a $120 minimum*/$300 maximum copay per initial fill and refill
Mail Order Program

(up to a 90-day supply)

You pay a $15 copay per initial fill and refill You pay 20% with a $40 minimum*/$200 maximum copay per initial fill and refill You pay 30% with a $80 minimum*/$200 maximum copay per initial fill and refill
Voluntary Self-Injectable Specialty Drug Program You pay 10% with a $10 minimum*/$100 maximum copay per initial fill and refill You pay 20% with a $15 minimum*/$100 maximum copay per initial fill and refill You pay 30% with a $30 minimum*/$100 maximum copay per initial fill and refill
Sav-Rx Network Usage Requirement Benefits are not payable for prescriptions filled at pharmacies that are not in the Sav-Rx network. Check to make sure that your pharmacy is part of the Sav-Rx network before filling your prescription. Note: Not all chains/pharmacies are in the Sav-Rx network, including Wal Mart, Sam’s Club, and certain Rite-Aid locations.
Generic Medication If your doctor indicates a generic medication is acceptable, but you choose to have your prescription filled with a preferred or non-preferred brand name drug, you must pay the difference in cost between the preferred or non-preferred brand name and the generic medication, plus the preferred or non-preferred brand name copayment amount.

*Note: If the cost of a medication is less than the minimum copay amount, you are responsible for the actual cost of the medication, plus the dispensing fee. For example, if a preferred brand name medication costs $7 (the Plan’s minimum copay is $20 retail/$40 mail order), you will pay $7, plus the dispensing fee—not the applicable minimum copay.

Note: Specialty drugs are generally high-cost drugs used to treat serious and/or chronic conditions. If your drug is part of the High Impact Advocacy Program you must fill your specialty medications through the Sav-Rx Specialty Pharmacy. If your specialty drug is not part of the High Impact Advocacy Program, you may fill your specialty medication through a participating pharmacy, the Mail Order Pharmacy or the Specialty Pharmacy.

Flexible Choice Plan

In-Network

HEALTHY LIFE Incentive

In-Network

No Incentive

Out-of-Network
Out-of-Pocket Maximum: Prescription Drug
Individual

$1,600

Not applicable
Family

$8,200

Not applicable
Note: Your in-network and out-of-network eligible expenses cross-apply and accumulate toward your in-network out-of-pocket maximum.

Amounts shown are what you pay at a Sav-Rx participating pharmacy (retail, preferred network retail pharmacy, or mail order).

Program Generic Drugs Preferred Brand Name Drugs Non-Preferred Brand Name Drugs
Retail Program

(up to a 34-day supply)

You pay 10% with a $10 minimum*/$100 maximum copay per initial fill and refill You pay 20% with a $15 minimum*/$100 maximum copay per initial fill and refill You pay 30% with a $30 minimum*/$100 maximum copay per initial fill and refill
Preferred Network Retail Pharmacy

(up to a 90-day supply)

You pay 10% with a $30 minimum*/$300 maximum copay per initial fill and refill You pay 20% with a $45 minimum*/$300 maximum copay per initial fill and refill You pay 30% with a $90 minimum*/$300 maximum copay per initial fill and refill
Mail Order Program

(up to a 90-day supply)

You pay a $15 copay per initial fill and refill You pay 20% with a $40 minimum*/$200 maximum copay per initial fill and refill You pay 30% with a $60 minimum*/$200 maximum copay per initial fill and refill
Voluntary Self-Injectable Specialty Drug Program You pay 10% with a $10 minimum*/$100 maximum copay per initial fill and refill You pay 20% with a $15 minimum*/$100 maximum copay per initial fill and refill You pay 30% with a $30 minimum*/$100 maximum copay per initial fill and refill
Sav-Rx Network Usage Requirement Benefits are not payable for prescriptions filled at pharmacies that are not in the Sav-Rx network. Check to make sure that your pharmacy is part of the Sav-Rx network before filling your prescription. Note: Not all chains/pharmacies are in the Sav-Rx network, including Wal Mart, Sam’s Club, and certain Rite-Aid locations.
Generic Medication If your doctor indicates a generic medication is acceptable, but you choose to have your prescription filled with a preferred or non-preferred brand name drug, you must pay the difference in cost between the preferred or non-preferred brand name and the generic medication, plus the preferred or non-preferred brand name copayment amount.

*Note: If the cost of a medication is less than the minimum copay amount, you are responsible for the actual cost of the medication, plus the dispensing fee. For example, if a preferred brand name medication costs $7 (the Plan’s minimum copay is $15 retail/$40 mail order), you will pay $7, plus the dispensing fee—not the applicable minimum copay.

Note: Specialty drugs are generally high-cost drugs used to treat serious and/or chronic conditions. If your drug is part of the High Impact Advocacy Program you must fill your specialty medications through the Sav-Rx Specialty Pharmacy. If your specialty drug is not part of the High Impact Advocacy Program, you may fill your specialty medication through a participating pharmacy, the Mail Order Pharmacy or the Specialty Pharmacy.