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Enhanced 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 DRUG BENEFITS
Participating Pharmacy
Mail Order
Prescription
Brand Name
Drugs
$20 copay or 20% of the actual cost up to $100 maximum, whichever is greater per 30-day supply
$40 copay or 15% of actual cost up to $200 maximum, whichever is greater per 90-day supply
Generic
Drugs
$5 copay or 10% of the actual cost, whichever is greater per 30-day supply
$10 copay or 10% of actual cost, whichever is greater per 90-day supply

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