Highlights of the Plan

Coverage Tier

Tier Name

In-Network* Benefit

Out-of-Network Benefit

Approved Over-the-Counter OTCYou pay $0 when prescribed and dispensed at an on-site clinicNot covered
Approved PreventiveACA 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 PreferredTier 1You pay 10% coinsurance ($5 minimum); some $0 copay exceptions noted in the Covered Medication Search
Generic Non-PreferredTier 2You pay 10% coinsurance  ($10 minimum)
Brand-Name PreferredTier 3You pay 20% coinsurance ($10 minimum)
Brand-Name Non-PreferredTier 4You pay 40% coinsurance ($10 minimum)
SpecialtyTier 5-6See “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 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
Out-of-Pocket Limit (Calendar Year)Included in the combined medical/prescription out-of-pocket limit of $8,700 person/$17,400 family for 2022 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
  • Home delivery (mail order): 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 Elixir (formerly known as EnvisionRxOptions) at (800) 361-4542
  • Contact Elixir Pharmacy home delivery (mail order) at (866) 909-5170

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.