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Prescription Brand Deductible and Generic Substitution

If you are a Member of the Premier, Basic or the MILA Medicare Wrap-Around Plan, you will pay a $500 family deductible for all brand name drugs when a generic equivalent is available (“multi-source brand drug”) and the prescribing physician directs that only the brand may be issued (either by indicating “Dispense As Written” [DAW] or otherwise). However, if the prescribing physician provides a written statement which is satisfactory to the Claims Administrator that you cannot take the generic drug for medical reasons unique to your situation, the multi-source brand drug will be issued and the deductible will be waived for that prescription.

If the prescribing physician has not marked the multi-source brand drug as DAW, the Plan requires that the pharmacist substitute the generic drug for the brand name drug to which it is equivalent when the prescription is filled. You will save money because you will be charged the generic copay instead of the brand copay. However, if you insist on the multi-source brand drug being issued, you will be charged the generic copay plus the excess cost of the multi-source brand drug; the Plan will pay only what it would have paid if the generic had been substituted.

After your family meets the deductible amount for multi-source brand drugs for the year, you pay the copay amount shown in the Premier, Basic or MILA Medicare Wrap-Around Plan Summary chart. The copay amount depends on the type of drug you purchase and whether you purchase the drug (1) from a retail pharmacy or (2) through the mail service or the Maintenance Choice program. This deductible is applied to all multi-source brand drug prescriptions filled at a retail pharmacy or at the CVS Caremark Mail Service Pharmacy. It does not apply if you fill a prescription for a generic drug or a brand name drug for which there is no generic equivalent drug.

If you are a Member of the Core Plan, the $500 deductible applies to each individual and it applies to all brand name drugs even if a generic equivalent does not exist. You will continue to pay the cost of all brand name drugs until the $500 deductible has been met. After that, the Plan will pay the balance of the cost of the brand name drugs after you have paid your copay.