You need drugs to treat name drugs [Plans should insert a There may be limitations on the types of drugs your illness or condition single amount or all covered. Please see <plan name>’s List of applicable copay Covered Drugs (Drug List) for more information. (continued) amounts for a tier with [Plans must indicate if extended-day supplies LIS copay amounts] for are available at retail and/or mail order a [must be at least pharmacy locations and make clear that the supply. cost sharing amount for these extended-day [Plans may delete the supplies is the same as for a one-month following statement if supply.] they charge $0 for all brand name drugs.] Copays for prescription drugs may vary based on the level of Extra Help you get. Please contact the plan for more details. Over-the-counter drugs [Plans There may be limitations on the types of drugs should insert a single amount, multiple covered. Please see <plan name>’s List of amounts, or Covered Drugs (Drug List) for more information. minimum/maximum range.]
You need drugs to treat your illness or condition (continued) name drugs [Plans should insert a single amount or all applicable copay amounts for a tier with LIS copay amounts] for a [must be at least supply. [Plans may delete the following statement if they charge $0 for all brand name drugs.] Copays for prescription drugs may vary based on the level of Extra Help you get. Please contact the plan for more details. There may be limitations on the types of drugs covered. Please see <plan name>’s List of Covered Drugs (Drug List) for more information. [Plans must indicate if extended-day supplies are available at retail and/or mail order pharmacy locations and make clear that the cost sharing amount for these extended-day supplies is the same as for a one-month supply.] Over-the-counter drugs [Plans should insert a single amount, multiple amounts, or minimum/maximum range.] There may be limitations on the types of drugs covered. Please see <plan name>’s List of Covered Drugs (Drug List) for more information.
OHSB2018.docx