Highlights of the Plan

Coverage Tier

In-Network* Benefit

Out-of-Network Benefit

Approved Over-the-Counter Drugs and Health Center DrugsYou pay $0 when prescribed and dispensed at an on-site Health CenterNot covered
Approved PreventiveYou 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-ManagementYou pay $5 copay
Generic Preferred DrugsYou pay $5 copay (some $0 copay exceptions noted in the Coverage Tiers [Formulary]
Generic Non-Preferred DrugsYou pay 10% ($10 minimum coinsurance)
Brand-Name Preferred DrugsYou pay 20% ($10 minimum coinsurance)
Brand-Name Non-Preferred DrugsYou pay 40% ($10 minimum coinsurance)
Specialty DrugsSee "Specialty Drugs"



Other HighlightsIn-Network* Benefit

Out-of-Network Benefit

DeductibleNone; you do not need to satisfy an annual deductible before the Plan pays expenses for the calendar yearNone
Annual Out-of-Pocket LimitIncluded 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 
  • Retail pharmacy: up to a 30-day supply
  • Mail-order pharmacy: up to a 90-day supply
 
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 
  • Contact EnvisionRxOptions at (800)361-4542
  • Contact EnvisionMail mail-order pharmacy at (866) 909-5170
 


* 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 Prescription Drug Coverage Tiers (Formulary); 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.