Prescription Drug Benefit

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.

Deductible

• $50 per member per contract year

Benefit Maximum

• $3,000 per member per contract year. After $3,000 benefit maximum has been exhausted, prescriptions will be covered at 50% coinsurance.

Benefit Limitations

• The Scott & White Health Plan will only cover the cost of the generic medications when they are available. If a brand name drug is dispensed when there is a generic available, the member will pay a 50% copayment.

Exclusions

• This drug benefit does not provide coverage for over-the-counter (OTC) medications and selected prescription drugs and therapeutic devices. Please refer to the prescription drug benefit rider included with your Scott & White Employee Medical Plan Summary Plan Description for further details on exclusions to this benefit. Common examples include but are not limited to drugs used primarily for cosmetic purposes, drugs used primarily for the treatment of infertility, contraceptive devices or implants, and drugs used primarily for weight loss.

Quantity Limitations (Unless otherwise specified on the SWHP Formulary)

• Non-Maintenance (All network pharmacies) - Up to a 34 day supply or 100 units (whichever is less), one retail copayment per prescription or refill prescription.
• Maintenance (For drugs on the SWHP Maintenance Drug List, SWHP pharmacies only) - Up to a 90 day supply or 360 units (whichever is less), one maintenance copayment per prescription or refill prescription.

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