ERS - Pharmacy Services PY2012
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State of Texas and Higher Education |
PY2012 |
Prescription Drug Benefit Summary
The Scott & White Health Plan uses a formulary (a list of drugs) that has been selected by a committee of Scott & White Physicians and Pharmacists. These medications are selected based on research that shows their safety and effectiveness. Since there can be many different brands of similar prescription medicines, the formulary is used to select the medication that proves to be most effective in treating an illness.
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Benefit Description
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Member Pays
FY 2012 |
| Plan Year Deductible |
$50 per person per plan year |
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If a brand-name medication is dispensed when a generic is available, member will be responsible for the generic copayment plus the cost difference between the generic and the brand-name medication. |
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Participating Retail Pharmacy -Tier 1/Tier 2/Tier 3 |
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Up to 30-day supply per prescription or refill of Non-Maintenance medication |
$15/$35/$60 |
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Up to a 30-day supply per prescription or refill of Maintenance medication |
$20/$45/$75 |
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Infertility drugs |
50% |
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Up to a 30-day supply of insulin for one copayment |
$15/$35/$60 |
| Up to a 30-day supply of each diabetic oral agent for one copayment |
$15/$35/$60 |
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The supply of necessary disposable syringes for the insulin supply for one copayment |
$35 |
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Diabetic supplies other than insulin, diabetic oral agent(s), and syringes as specified in Section 1358.051(2), Tex. Ins. Code up to a 30-day supply. |
20% |
| Mail Order Pharmacy -Tier 1/Tier 2/Tier 3 | |
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Up to a 90-day supply per prescripton or refill for one mail order copayment. |
$45/$105/$180 |
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Oral contraceptives up to a 90-day supply for one mail order copayment |
$45/$105/$180 |
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Infertility drugs |
50% |
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Up to a 90-day supply of insulin for one mail order copayment |
$45/$105/$180 |
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Up to a 90-day supply of each diabetic oral agent for one mail order copayment |
$45/$105/$180 |
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The supply of necessary disposable syringes for the insulin supply for one mail order copayment |
$105 |
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Diabetic supplies other than insulin, diabetic oral agent(s), and syringes as specified in Section 1358.051(2), Tex. Ins. Code up to a 90-day supply. |
20% |
