AtlantiCare Benefits Book 2020

Prescription Drug

HOME TABL OF CONTENTS WELCOME.................2 WHAT’S NEW. ...........3 I E CENTERS AND WEBSITES...................4 HO TO ENROLL.......5 MEDICAL..............6-12 PRESCRIPTION DRUG. ................13-15 ADDITIONAL MEDICAL PLAN RESOURCES.........16-18 DENTAL...............19-21 VISION.....................22 LIFECENTER..............23 LIFE INSURANCE. .....24 LONG TERM DISABILITY...............25 VOLUNTARY OFFERINGS. ........26-29 SPENDING ACCOU TS. ............30 RETIREMENT B NEFITS..................31 WELLNESS. .........32-36 LEGAL NOTICES..37-39 CONTACTS.........40-41 GLOSSARY..........42-43 FAQs...................44-46 FORMS................47-56 WHAT’S NEW SERVICE CENTERS AND WEBSITES HOW TO ENROLL MEDICAL PRESCRIPTION DRUG ADDITIONAL MEDICAL PLAN RESOURCES DENTAL VISION LIFE INSURANCE LONG TERM DISABILITY VOLUNTARY OFFERINGS SPENDING ACCOUNTS RETIREMENT BENEFITS WELLNESS LEGAL NOTICES CONTACTS GLOSSARY

Regardless of which medical plan option you choose, you are eligible for prescription drug benefits through Geisinger. Refer to the table below for the copay amounts you will pay under the Prescription Drug plan. For more information about prescription benefits, see Prescription Plan FAQs on page 46 .

Non-Specialty Medications

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

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

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

Copays for 30-day supply 10% 20% 100%

Minimum $10 $25 N/A

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

*Other Specialty Pharmacy Generic Brand Formulary Brand Non-Formulary Maximum $150 $150 $150 *If the AtlantiCare Pharmacy is unable to fill your request, they will direct you to contact Geisinger Customer Service for assistance in obtaining your medication. Copays (up to 30-day supply) 10% 20% 30%

FORMS

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