|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|
|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 $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|| |
|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|| |
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.