Highlights of the Plan
Coverage Tier | Tier Name | In-Network* Benefit | Out-of-Network Benefit |
| Approved Over-the-Counter | OTC | You pay $0 when prescribed and dispensed at an on-site clinic | Not covered |
| Approved Preventive | ACA PV** | You pay $0 (certain drugs covered only when dispensed at an on-site clinic***) | 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 Elixir-discounted amount less your coinsurance) |
| Generic Preferred | Tier 1 | You pay 10% coinsurance ($5 minimum); some $0 copay exceptions noted in the Covered Medication Search | |
| Generic Non-Preferred | Tier 2 | You pay 10% coinsurance ($10 minimum) | |
| Brand-Name Preferred | Tier 3 | You pay 20% coinsurance ($10 minimum) | |
| Brand-Name Non-Preferred | Tier 4 | You pay 40% coinsurance ($10 minimum) | |
| Specialty | Tier 5-6 | See “Specialty Drugs” |
* Includes more than 60,000 retail pharmacies that participate in the Elixir network, and includes the Elixir Pharmacy.
** Medications designated as preventive (PV) by the Affordable Care Act (ACA)
*** If a clinic is not available at your mine/office, these drugs are covered 100% at an In-Network retail pharmacy.
| 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 | |
| Out-of-Pocket Limit (Calendar Year) | Included in the combined medical/prescription out-of-pocket limit of $9,100 person/$18,200 family for 2023 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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For certain medications, 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 details, review the full Prescription Drug Plan section of this handbook and refer to the Covered Medication Search tool; for additional information, call Elixir Customer Service at (800) 361-4542. In-Network pharmacists always have access to up-to-date information in the Elixir claims system; they can inform you of your share of the cost before you complete any purchases.
