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.
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