Mandatory Generic. Substitution If you choose a Non-preferred Brand drug (Tier 3) instead of its Generic equivalent, you will pay the highest copay plus, the difference in cost between the Non-preferred Brand drug and the Generic. If a Generic version is not available, you will only pay the copay. Delta Dental Plan Benefit Highlights for: Harford County Public Schools Group No: 00528 - PPO - Comprehensive Eligibility Primary enrollee, spouse and eligible dependent children to the end of the month dependent turns age 26 Deductibles Deductibles waived for Diagnostic & Preventive (D & P) and Orthodontics? Delta Dental PPO dentists: $25 per person / $50 per family each plan year Non-Delta Dental PPO dentists: $50 per person / $150 per family each plan year Yes Maximums D & P counts toward maximum? $1,500 per person each plan year No Waiting Period(s) Basic Benefits None Major Benefits None Prosthodontics None Orthodontics None Benefits and Covered Services* Delta Dental PPO dentists** Non-Delta Dental PPO dentists** Diagnostic & Preventive Services Exams, cleanings, x-rays and sealants 100 % 65 % Surgical Removal of Impacted Teeth 100 % 65 % Basic Services Fillings, denture repair/relining, stainless steel crowns, bridges, bridge recementation/repair and posterior composite restorations 80 % 50 % Endodontics (root canals) Covered Under Basic Services 80 % 50 % Periodontics (gum treatment) Covered Under Basic Services 80 % 50 % Oral Surgery Covered Under Basic Services 80 % 50 % Major Services Crowns, inlays, onlays and cast restorations 50 % 30 % Prosthodontics Dentures 50 % 30 % Implants Covered only as an alternative to a fixed bridge 80 % 50 % Orthodontic Benefits Dependent children to age 19 50 % 50 % Orthodontic Maximums $800 Lifetime $800 Lifetime * Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan. Reimbursement is based on Delta Dental maximum contract allowances and not necessarily each dentist’s submitted fees. ** Reimbursement is based on PPO contracted fees for PPO dentists, PPO contracted fees for Premier dentists and PPO contracted fees for non-Delta Dental dentists. Delta Dental of Pennsylvania Xxx Xxxxx Xxxxx Xxxxxxxxxxxxx, XX 00000 Customer Service 800-932-0783 xxxxxxxxxxxxxx.xxx Claims Address X.X. Xxx 0000 Xxxxxxxxxxxxx, XX 00000-0000 This benefit information is not intended or designed to replace or serve as the plan’s Evidence of Coverage or Summary Plan Description. If you have specific questions regard...
Mandatory Generic. (d) Open contraceptives to be included. (Company agrees to coverage with a prescription- no maximum)
Mandatory Generic. The prescription drug co-pays will be $5.00 generic/$15.00 name-brand. Generic drugs must be utilized if available, unless a physician orders otherwise and documents in writing the reason(s) the name-brand is medically necessary.
Mandatory Generic. Whenever generic drugs are available, plan participants must utilize them or they will be responsible for the difference in cost between the generic and the brand name drug. In the event the generic is not effective or tolerated by the participant, they or their doctor may appeal based on medical necessity as follows: Appeals Procedure for obtaining a Brand Name Drug when a Generic is available: If a participant in the CWA pharmacy plan finds that there is a medical necessity for a name brand drug when a generic drug is available, the participant or their doctor can file an appeal. If the appeal is granted, the participant can then obtain the name brand drug by paying the standard co-pay for a Non-Formulary name brand drug through the CWA Pharmacy Plan. The appeals procedure is as follows: Participant must provide a written letter from the prescribing physician on the physician’s office letterhead in which the physician indicates that there is a MEDICAL NECESSITY for the patient to use the name brand drug. This letter should also indicate the physician’s reason for her/his opinion that there is a medical necessity for the name brand drug. The above document should be mailed, emailed or faxed to CWA’s Human Resources Department within one week of the date of the physician’s letter. A decision will be forthcoming within one week of receipt of the physician’s letter and will be effective retroactive to the date of the physician’s letter.
Mandatory Generic. Formulary (6) $10 generic/$20 brand copayment Greater of 34 day supply or 100 units Not Covered Mail Order Prescriptions $20 generic/$40 brand copayment Not Covered Syringes (covered under prescription plan)
Mandatory Generic. Substitution with DAW 2 (i.e., the only exception is physician ordered "Dispense as Written")
