Plan pays 100% (If no Plan pays 100% (If no Plan pays 100% (If no generic available) generic available) generic available) COST-SHARING COST-SHARING COST-SHARING POPULATION: POPULATION: 2. Formulary brand name Plan pays 100% (If no POPULATION: *Prescription Drugs - $8.00 *Prescription Drugs - $8.00 drugs per prescription unit generic available) *Prescription - $2.50 co-payment per co-payment per co-payment per prescription prescription drug that prescription drug that drug that agency pays $25 & agency pays $25 & above agency pays $25 & above above per prescription drug. per prescription drug. per prescription drug. 3. Mail Not Applicable Not Applicable Plan pays 100%, no copay Plan pays 100%, no copay Plan pays 100% Plan pays 100% Plan pays 100% COST-SHARING COST-SHARING COST-SHARING POPULATION: POPULATION: POPULATION: 4. Non-Formulary (Medically *Prescription Drugs - $2.50 *Prescription Drugs - $8.00 *Prescription Drugs - $8.00 Necessary Only and Plan pays 100% co-payment per prescription co-payment per co-payment per Required) drug that agency pays $25 & prescription drug that prescription drug that above per prescription agency pays $25 & above agency pays $25 & above drug. per prescription drug. per prescription drug. Plan pays 100% Plan pays 100% Plan pays 100% COST-SHARING COST-SHARING COST-SHARING POPULATION: POPULATION: 5. Specialty Drugs (Medically POPULATION: *Prescription Drugs - $8.00 *Prescription Drugs - $8.00 Necessary Only and Plan pays 100% *Prescription Drugs - $2.50 co-payment per co-payment per Required) co-payment per prescription prescription drug that prescription drug that drug that agency pays $25 & agency pays $25 & above agency pays $25 & above above per prescription drug. per prescription drug. per prescription drug.
2. Formulary brand name drugs per prescription unit Plan pays 100% (If no generic available) Plan pays 100% (If no generic available) COST-SHARING POPULATION: *Prescription - $2.50 co-payment per prescription drug that agency pays $25 & above per prescription drug. Plan pays 100% (If no generic available) COST-SHARING POPULATION: *Prescription Drugs - $8.00 co-payment per prescription drug that agency pays $25 & above per prescription drug. Plan pays 100% (If no generic available) COST-SHARING POPULATION: *Prescription Drugs - $8.00 co-payment per prescription drug that agency pays $25 & above per prescription drug. 3. Mail Not Applicable Not Applicable Plan pays 100%, no copay Plan pays 100%, no copay 4. Non-Formulary (Medically Necessary Only and Required) Plan pays 100% Plan pays 100% COST-SHARING POPULATION: *Prescription Drugs - $2.50 co-payment per prescription drug that agency pays $25 & above per prescription drug. Plan pays 100% COST-SHARING POPULATION: *Prescription Drugs - $8.00 co-payment per prescription drug that agency pays $25 & above per prescription drug. Plan pays 100% COST-SHARING POPULATION: *Prescription Drugs - $8.00 co-payment per prescription drug that agency pays $25 & above per prescription drug. 5. Specialty Drugs (Medically Necessary Only and Required) Plan pays 100% Plan pays 100% COST-SHARING POPULATION: *Prescription Drugs - $2.50 co-payment per prescription drug that agency pays $25 & above per prescription drug. Plan pays 100% COST-SHARING POPULATION: *Prescription Drugs - $8.00 co-payment per prescription drug that agency pays $25 & above per prescription drug. Plan pays 100% COST-SHARING POPULATION: *Prescription Drugs - $8.00 co-payment per prescription drug that agency pays $25 & above per prescription drug.