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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- to 90-day supplies may not be available at all retail locations.

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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