Member pays the cost of the drug or the copayment, whichever is less. If a member requests a brand-name drug when a generic is available, the member pays the generic copayment plus the difference in the cost of the drugs.
There are certain medications that MCHCP covers at 100%, when accompanied by a prescription and filled at a network pharmacy. For more information, see Preventive Services.
Note: 32- to 60-day and 61-90-day supplies may not be available at all retail locations.
| Plan | Type | Retail Network one-month (31-day supply) |
Retail Network two-month (60-day supply) |
Retail Network three-month (90-day supply) |
Home Delivery three-month (90-day supply) |
Retail Non-Network one-month (31-day supply) |
|---|---|---|---|---|---|---|
| HSA Plan Coinsurance |
Generic | Retail Network (31-day supply) — 10% up to $50 | Retail Network (60-day supply) — 10% up to $100 | Retail Network (90-day supply) — 10% up to $150 | Home Delivery Network (90-day supply) — 10% up to $150 | Retail Non-Network (31-day supply) — 40% |
| Preferred | Retail Network (31-day supply) — 20% up to $100 | Retail Network (60-day supply) — 20% up to $200 | Retail Network (90-day supply) — 20% up to $300 | Home Delivery Network (90-day supply) — 20% up to $300 | Retail Non-Network (31-day supply) — 40% | |
| Non-Preferred | Retail Network (31-day supply) — 40% up to $200 | Retail Network (60-day supply) — 40% up to $400 | Retail Network (90-day supply) — 40% up to $600 | Home Delivery Network (90-day supply) — 40% up to $600 | Retail Non-Network (31-day supply) — 50% | |
| PPO Plans Copayment |
Generic | Retail Network (31-day supply) — $10 | Retail Network (60-day supply) — $20 | Retail Network (90-day supply) — $30 | Home Delivery Network (90-day supply) — $25 | Retail Non-Network (31-day supply) — $10 |
| Preferred | Retail Network (31-day supply) — $40 | Retail Network (60-day supply) — $80 | Retail Network (90-day supply) — $120 | Home Delivery Network (90-day supply) — $100 | Retail Non-Network (31-day supply) — $40 | |
| Non-Preferred | Retail Network (31-day supply) — $100 | Retail Network (60-day supply) — $200 | Retail Network (90-day supply) — $300 | Home Delivery Network (90-day supply) — $250 | Retail Non-Network (31-day supply) — $100 |
To fill prescriptions at a non-network pharmacy on HSA Plan or PPO Plans...
To fill prescriptions at a non-network pharmacy on HSA Plan or PPO Plans...
Members must pay the full price of the prescription and file a completed claim form with ESI within 365 days of the incurred expense. Members are reimbursed the network discounted amount, less the applicable copayment or coinsurance.
Attach a prescription receipt or label from the pharmacy to the claim form. Patient history printouts from the pharmacy are acceptable, but must be signed by the pharmacist. Cash register receipts are acceptable only for diabetic supplies.
| Description | HSA Plan | PPO Plans |
|---|---|---|
| Specialty (up to 31-day supply) | HSA Plan — | PPO Plans $75 through Accredo |
| Prescription Out-of-Pocket Maximum Network — Individual Network — Family Non-Network |
HSA Plan Combined with medical Combined with medical Combined with medical |
PPO Plans Network (Individual) — $4,150 Network (Family) — $8,300 Non-Network — No maximum |
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