Basic Prescriptions
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These pharmacy benefits apply to participants in all three Active Health Programs.
This program allows you to use a participating network pharmacy for all drug purchases and you do not need a claim form. Generic drugs will always be dispensed unless you or your physician request brand name drugs. If you obtain a brand-name drug, you pay a higher copayment. In addition, you must pay for the additional ingredient cost of the brand-name drug.
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Walk-in Pharmacy Benefits
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| Category |
Your Copay |
Generic - 30 day supply |
$0 |
| Generic (maintenance drugs) - 100 day supply |
$0 |
| Brand-name 30 day supply (when generic not available) |
$10 |
| Brand-name (maintenance drugs) 100 day supply (when generic not available) |
$20 |
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Mail Service Pharmacy Benefits for Maintenance Drugs
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| Category |
Your Copay |
| Generic - 100 day supply |
$0 |
| Brand-name 100 day supply (when generic not available) |
$20 |
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Non-Network Pharmacy Benefits
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You must file a claim to be reimbursed for your drugs within 15 months of the purchase. This option is intended for emergencies or when travelling only. Reimbursement is limited by the
Plan's average costs for prescriptions; you will pay for amounts over the limits in addition to the copay.
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Network Pharmacy Chains
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Albertsons, Big "A" Drug Stores, Costco, Gemmel Pharmacy, Horton and Converse, K-Mart Pharmacies, Longs, Medicine Shoppe, Pavilions Pharmacies, Raley's Super Stores, Ralphs, Rite Aid, Safeway Pharmacy, Savemart Supermarkets, Sav-On Drugs, Scolari's Food & Drug, Shopko Stores, Target, Vons/ Pavilions Pharmacies, Walgreens.
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Limitations
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Certain limitations apply to the following covered benefits: smoking deterrents, morning after pills & kits, and drugs to treat erectile dysfunction. Amendment 33 to the Active Health Plan Summary Plan Description details these limitations.
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Additional Information
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Prescription Solutions
Customer Service Phone Number: 1-800-797-9791
Website: www.rxsolutions.com
Group # IBEW
PCN #: 9999
BIN #: 610494
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