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<br />- <br /> <br />OPTIONAL BENEFITS <br /> <br />RA TES <br />MANDATORY <br /> <br />OPTION I - PRESCRIPTION BENEFITS (PHARMACARE FORMULARY) <br />A. Prescription Drugs <br />Retail (30 days) .... $300 Deductible; $5,000 Calendar Maximum <br /> <br />Retiree Only <br />Retiree & Spouse <br /> <br />$126.50 <br />$253.00 <br /> <br />Preferred Brand Drugs <br /> <br />$35 or 50% copay, whichever is greater <br />(generic substitution is required) <br />$15 Copay <br />100% copay with Member discount <br /> <br />Generic Drugs <br />Retail Non-Preferred Brand <br />Mail Order (90 days) <br />Generic <br />Preferred Brand <br />Non-Preferred Brand <br /> <br />$45 Copay <br />$105 or 50% copay, whichever is greater <br />100% copay with Member discount <br /> <br />B. <br /> <br />Prescription Drugs (Catalyst Generic Only Formulary) <br />$100 Deductible; $5,000 Calendar Year Maximum <br />Generic (Formulary) Drugs <br />Generic (Non-Formulary) Drugs <br />Brand Drugs <br />No Mail Order <br /> <br />Retiree Only $31.20 <br />Retiree + Child(ren) $49.53 <br />$10 copay Retiree + Spouse $56.28 <br />100% copay with Member discount Family $81.50 <br />100% copay with Member discount <br /> <br />C. <br /> <br />Generic (Formulary) Drugs <br />Generic (Non-Formulary) Drugs <br />Brand (Open Formulary) Drugs <br /> <br />Retiree Only $59.95 <br />Retiree + Child(ren) $95.30 <br />Retiree + Spouse $109.20 <br />$10 copay Family $156.50 <br />100% copay with Member discount <br />$35 or 50% copay whichever is greater <br /> <br />Prescription Drugs (Catalyst GenericlBrand with Open Formulary) <br />$100 Deductible; $5,000 Calendar Year Maximum; $400 Calendar Year Maximum on Brand <br />Drugs <br /> <br />D. <br /> <br />Retiree Only $88.89 <br />Retiree + Child(ren) $143.78 <br />Retiree + Spouse $168.89 <br />Family $215.68 <br /> <br />Prescription Drugs (SavRx Minimal Formulary) <br />$100 Deductible; $5,000 Calendar Year Maximum <br />Generic (Formulary) Drugs <br />Generic (Non-Formulary) Drugs <br />Brand (Formulary) Drugs <br /> <br />$14 Copay <br />100% copay with Member discount <br />$30 Copay <br />(generic substitution required) <br />100% copay with Member discount <br /> <br />Brand (Non-Formulary) Drugs <br />Mail Order (30 day dispensement) <br />Generic (Formulary) <br />Brand (Formulary) <br />Brand (Non-Formulary) <br /> <br />$9 Copay <br />$25 Copay <br />100% copay with Member discount <br /> <br />E. <br /> <br />BeneScript Prescription Drug Discount Card <br />Discounts of up to 25% off of average wholesale drug prices are provided through a network <br />of 45,000 national, regional and local participating pharmacies (including Walgreen's, <br />Walmart, CVS and Target). To find a phannacy near you, go to: www.benescriotcom. <br /> <br />Optional <br />Retiree $4.00 <br />Family $8.00 <br />If employer not going with other <br />Rx option <br /> <br />. <br />C:\Documents and Settings\ganderson\LocaJ Settings\TelJ1X>rary Internet FiJes\OLK5\EarlyReLdoc <br />