PRESCRIPTION BENEFIT

Tri-County Schools Insurance Group offers several methods for you to obtain your prescriptions.

Retail Pharmacy - 31-Day Supply:

Present your medical I.D. card with your prescription. The pharmacist will fill your prescription and submit your claim electronically for you. You will be charged a copay based on the following criteria:

• Generic - $7
• Preferred Brand - 25% to a maximum of $35
• Non-Preferred Brand - 45% to a maximum of $70

Retail 90-Day Supply:

Currently available at the following pharmacies: CVS, Longs, Raley's, Rite Aid or Walgreens.

• Generic - $14
• Preferred Brand - $50
• Non-Preferred Brand - $90

When the retail cost of a Preferred or Non-Preferred Brand name drug is more than $67.00, you can save money using the Retail 90-day supply program.

• This program was designed for individuals using maintenance medications for long-term medical conditions.
• Have your doctor write your prescription for a 90-day supply with three refills, if appropriate.

Mail Order Pharmacy - 90-Day Supply:

• Generic - $14
• Preferred Brand - $50
• Non-Preferred Brand - $90

When the retail cost of a Preferred or Non-Preferred Brand name drug is more than $67.00, you can save money using the mail order pharmacy.

• This program was designed for individuals using maintenance medications for long-term medical conditions.
• Have your doctor write your prescription for a 90-day supply with three refills, if appropriate.
• Complete the Order Form and Patient Profile questionnaire. The questionnaire will only need to be completed with your first order.
• Select method of payment, i.e., credit card or check
• Online ordering is available after your initial order.

A covered person may elect a brand name product when a generic is available; however, the covered person will be liable for the difference in cost between the brand name and the generic drug along with the brand name copay.

A generic or formulary drug will automatically be substituted for a brand name drug unless there are health reasons and a letter of medical necessity from the prescribing physician has been received and approved by a panel of clinical pharmacists at EnvisionRxOptions. For your convenience letters of medical necessity can be faxed by the physician's office directly to Envision's clinical staff (330) 405-8081.