Welfare Summary Plan Description

PRESCRIPTION DRUG BENEFIT – See Section 8

Benefit Funded by the Trust
A separate maximum out-of-pocket limit applies to prescription drugs: For Active Participants $3,200 per Individual, $6,000 per Family.

  Participating Retail Pharmacy**
(34-Day Supply)
Preferred Participating Mail Order Pharmacy Non-Participating Pharmacy***
Generic Drugs Participant co-payment is 20% of the total cost of the Drug. Participant co-payment is the lesser of 20% of the cost of the drug or $20 for each prescription. No reimbursement.
Preferred Brand-name Drugs*
Reimbursement Limitations apply, see below*
Participant co-payment is 35% of the total cost of the Drug. Participant co-payment is the lesser of 35% of the cost of the drug or $50 for each prescription. No reimbursement.
Non-Preferred Brandname Drugs*
Reimbursement Limitations apply, see below*
Participant co-payment is 50% of the total cost of the Drug. Participant co-payment is the lesser of 50% of the cost of the drug or $100 for each prescription. No reimbursement.
Specialty Drugs(*)
Must be filled at participating Specialty Drug mail order facility
Not applicable. Participant co-payment is $100 for each Specialty prescription. 30 day supply. No reimbursement

If filled through a participating retail pharmacy, the Plan also covers medications and supplements that are designated as "preventive care" under Health Care Reform and which the Plan is required by law to provide. For a list of the covered medications and supplements, see www.hhs.gov/. These items are covered at 100% innetwork, but you must have a prescription from your doctor (even for the over-the-counter items). Also, not all items are covered for everybody - for example, there are age restrictions, and some items are limited to generic
only. Contact the Pharmaceutical Provider for more information.

* REIMBURSEMENT LIMITATIONS:
If you or your Physician request that your prescription be filled with a brand-name Drug when a generic equivalent is available, you will be responsible for paying the full difference in price between the generic and brand-name Drug in addition to your brand-name Prescription Drug co-payment. The generic drug price is established by the Plan's Pharmaceutical Provider.

If you fail to use your prescription drug card at a participating pharmacy, there is no reimbursement.

*** OUT-OF-NETWORK:
If no in-network pharmacy is located in the area, the copayment is 50% of the Drug cost per each prescription filled out-of-network.