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Pharmacy Co-payments Effective May 1, 2014

CO-PAYMENT CHANGE

Please be advised that pharmacy co-payments will change as of May 1, 2014. Co-payments will once again be assessed on the total allowed charge for the prescription, regardless of preferred or non-preferred status.

The table below displays the new co-payment structure. All member categories previously excluded from co-pays will continue to be excluded.

Total Allowed Charge

Co-Payment

$0.00-$5.00

$0.00

$5.01-$10.00

$0.50

$10.01-$25.00

$1.00

$25.01-$50.00

$2.00

$50.01 and above

$3.00

Beginning April 1, 2014, members will have a maximum out-of-pocket payment. The most the member will be required to pay for prescription drugs is displayed in the table below.

Tier Level and Federal Poverty Level (FPL)

Maximum Out-of-Pocket per Household

1 (Below 50% of FPL)

$8.00

2 (50.01%-100% of FPL)

$71.00

3 100.01%-150% of FPL)

$143.00




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