2023 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 47
PRESCRIPTION DRUG SCHEDULE OF BENEFITS
BENEFIT DESCRIPTION
BENEFIT
NOTE: Prescription Drugs may be obtained from any retail or mail order pharmacy.
However, Prescription Drugs obtained from a Non-Participating Provider will be paid at NonParticipating Provider rates.
Retail Pharmacy: 34-day supply or 100 unit dose
(whichever is greater)
Generic Drug
Brand Name Drug
$10 Copay, then 100%
$30 Copay, then 100%
Mail Order Pharmacy: 90-day supply or 300 unit
dose (whichever is greater)
Generic Drug
Brand Name Drug
$20 Copay, then 100%
$60 Copay, then 100%
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