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Catastrophic (CAT) Plan
Prescription Drug Benefit Highlights



This plan provides Prescription Drug benefits for Prescription Drugs and Related Supplies provided by Pharmacies as shown in this Schedule. To receive Prescription Drug Benefits, you and your Dependents may be required to pay a portion of the Covered Expenses for Prescription Drugs and Related Supplies for each 30-day supply at a retail pharmacy or each 90-day supply at a mail order pharmacy. That portion is the Copayment or Coinsurance.

Coinsurance
The term Coinsurance means the percentage of charges for covered Prescription Drugs and Related Supplies that you or your Dependent are required to pay under this plan.

Copayments
Copayments are expenses to be paid by you and your Dependent for covered Prescription Drugs an Related Supplies. Copayments are in addition to any Coinsurance.


Prescription Benefits
Retail (Participating Pharmacy) Mail order through Tel-Drug
(Limited to a 30-day supply)(Limited to a 90-day supply)
Generic10% of the actual cost*10% of the actual cost*
Brand Name30% of the actual cost, up to $150 maximum per prescription25% of the actual cost, up to $300 maximum per prescription

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