2023 AtlantiCare Benefits Booklet

Prescription Drug

TABLE OF CONTENTS WELCOME.................2 WHAT’S NEW. ...........3 SERVICE CENTERS AND WEBSITES..........4 HOW TO ENROLL....5-6 MEDICAL..............7-14 PRESCRIPTION DRUG. ................15-17 ADDITIONAL MEDICAL PLAN RESOURCES........18-22 DENTAL...............23-24 VISION.....................25 LIFECENTER..............26 LIFE INSURANCE. .....27 DISABILITY...............28 VOLUNTARY OFFERINGS. ........29-32 SPENDING ACCOUNTS. ............33 RETIREMENT BENEFITS..................34 WELLNESS. .........35-38 LEGAL NOTICES...39-41 GLOSSARY..........42-43 FAQs...................44-46 CONTACTS.........47-48 FORMS................49-58

Regardless of which medical plan option you choose, you automatically receive prescription drug coverage through MedImpact. You do not need to enroll separately in the prescription plan. Prescription coverage is included as part of the Medical plan enrollment. Your prescription plan information can be found on your prescription ID card.

Should you need a replacement ID card, please call MedImpact Customer Service at 1-833-229-3595 .

Refer to the table below for the copay amounts you will pay under the Prescription Drug plan. The maximum amount that you will pay for prescriptions per year: Single $1,750/Family $3,500. For more information about prescription benefits, see Prescription Plan FAQs on page 46.

Non-Specialty Medications

AtlantiCare Pharmacy (Retail & Mail Order) Generic Brand Preferred Brand Non-Preferred

Copays for 30/90-day supply $10/$20 $20/$40 $50/$100

Non-AtlantiCare Retail Pharmacy Generic Brand Preferred Brand Non-Preferred Specialty Medications AtlantiCare Retail Pharmacy Generic Brand Preferred Brand Non-Preferred

Copays for 30-day supply 15% 30% 100%

Minimum $15 $50 N/A

Copays (up to 30-day supply) $10 $20 $50

*Other Specialty Pharmacy Generic Brand Preferred Brand Non-Preferred

Copays (up to 30-day supply) 10% 20% 30%

Maximum $150 $150 $150

*If the AtlantiCare Pharmacy is unable to fill your request, they will direct you to contact MedImpact Customer Service for assistance in obtaining your medication.

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