Summary Plan Description

Copayments

The patient is responsible for certain copayment expenses each time certain covered medical expenses are incurred. Each person covered under the plan has his or her own copayments. Copayments do not apply toward the $200 annual deductible or $2,300 annual coinsurance maximum.

Network Office Visit Copayment

The patient is responsible for a $10 copayment when a network provider bills an office visit.

Non-Network Office Visit Copayment

The patient is responsible for a $20 copayment when a non-network provider bills an office visit.

Non-Network Inpatient Facility Copayment

The patient is responsible for a $200 copayment for inpatient admissions at a non-network facility.

$50 Emergency Room Copayment

The patient is responsible for a $50 copayment for an emergency room visit. If the patient is admitted as an inpatient directly following treatment in the emergency room, the $50 copayment is waived.

Prescription Copayments – Dollar Bank Eligibility and Early Retirees

Express Scripts Retail Pharmacy Program

The following copayments apply to the retail pharmacy program. There is a 30-day maximum supply.

  • $7 copayment for each generic prescription.
  • $15 copayment for each brand-name prescription listed on the drug program formulary.
  • $30 copayment for each brand-name prescription not listed on the drug program formulary.

Express Scripts By Mail

The following copayments apply to the mail pharmacy program. There is a 90-day maximum supply.

  • $14 copayment for each generic prescription.
  • $30 copayment for each brand-name prescription listed on the drug program formulary.
  • $60 copayment for each brand-name prescription drug not listed on the drug program formulary.

Prescription Copayments – Medicare

The prescription copayments under the Express Scripts Medicare Prescription Drug Program are provided each year during the annual enrollment process.