Date

Express Scripts Pharmacy Percentage Co-Payment Plan 1 — P 1

Administered by Express Scripts: 1-800-841-2806
Plan Feature
Retail Pharmacy Benefit
Express Scripts by Mail (Mail-Order) Benefit
Annual Deductible1
Annual Out-of-Pocket (OOP)
Maximum2, 3
Generic Drugs (Tier 1)4
Preferred Brand-Name Drugs
(Tier 2)4
Non-Preferred Brand-Name
Drugs (Tier 3)4
Prescription Non-Sedating
Antihistamine Drugs (e.g.,
Xyzal and Clarinex)
Retail Refill Allowance (RRA)
Participants will be allowed to obtain three fills of maintenance medication at the retail pharmacy. For all subsequent fills at the retail pharmacy, participants will be responsible for paying 100% of the discounted cost. To maximize Plan benefits, refills for most maintenance medications will require fulfillment through the Express Scripts by Mail Pharmacy Program.
Example:
The following example illustrates how this percentage co-payment works:
Suppose a preferred brand-name drug costs $160 for a 90-day supply by mail order, and costs $48 for a 30-day supply
at a retail pharmacy. For one fill at the local pharmacy, you will pay $15. (Please note: 20% of $48 is $9.60; however,
the minimum payment for this category drug is $15.) For a 90-day supply through Express Scripts by Mail, you will
pay $40. (Please note: 20% of $160 is $32; however, the minimum payment for this category drug is $40.)
1 The Annual Deductible for prescription drugs is separate from the medical plan deductible.
2 Excludes co-payments for non-preferred brand-name drugs and additional costs incurred when a brand-name drug is chosen but a generic
3 There is one Annual Out-of-Pocket (OOP) Maximum that includes charges incurred through the retail pharmacy and Express Scripts by Mail
(mail order). The prescription drug OOP Maximum is separate from the medical OOP Maximum. 4 Due to federal health care reform legislation enacted in 2010, certain preventive drugs may have a different co-payment. If you wish to
know which drugs are impacted, contact Express Scripts at 1-800-841-2806. In addition, certain prescribed over-the-counter (OTC)

Additional Information
• Patient is required to pay the generic co-payment plus the difference in cost between the generic and brand-name drug
when the brand-name is chosen and a generic is available. The additional cost does not apply to the Annual Out-of-Pocket Maximum. • Some medications may be covered by your benefit plan only for certain uses or in certain quantities. For example, a medication may not be covered when it is used for cosmetic purposes, or a quantity may be limited to certain amounts
over certain time periods. You may contact Express Scripts at 1-800-841-2806 if you have any questions.
• If you purchase a prescription without using your Blue Cross and Blue Shield of Illinois or UnitedHealthcare card, you will need to complete a Prescription Drug Reimbursement Claim Form. You can obtain the form by visiting
www.medco.com or by calling 1-800-841-2806 to speak to a customer service representative. Prescriptions purchased
at a non-participating pharmacy are processed as out of network and may be subject to a higher co-payment. Any
difference between the amount submitted (retail cost) and the amount approved is not reimbursable. The reimbursement
rate is also determined after the deductible and co-payments are subtracted.
This summary highlights some of the features of this benefit plan. The summary is for illustrative purposes only and is subject to change at any time. The controlling terms and conditions of the benefit plan are contained in the Plan Document, the Summary Plan Description and the HealthFlex Benefit Booklet (collectively, the “Documents”) maintained by the General Board of Pension and Health Benefits. If there are any conflicts between this summary and the terms of the Documents, the terms of the Documents shall control.

Source: http://www.wisconsinumc.org/content/Finance/Documents/ExpressScriptsP1.pdf