Medical Mutual Prescription Drug Program
www.medco.com

A "Home Delivery Incentive" option has been added to the prescription drug program. When a member chooses to fill a prescription a third time at a retail pharmacy within 180 days, the member will pay twice the normal retail co-payment. (Example: if a member purchases a "maintenance" medication from a pharmacy that has a $20 co-pay, beginning with the third fill at the pharmacy the member will be charged a $40 co-pay.)

Benefits Co-pay Day Supply
Benefit Period January 1st through December 31st
Dependent Age Limit 19-Dependent   24-Student
Removal upon end of calendar year
Formulary¹ Retail Program with Oral Contraceptive Coverage - for the initial filling and one refill of a prescription drug
Generic Co-payment $10 30
Formulary Co-payment $20 30
Non-Formulary Co-payment $30 30
Diabetic Supplies² $0 30
Asthmatic Supplies³ $0 30
Formulary Retail Program with Oral Contraceptive Coverage - after the 2nd retail fill of a prescription drug*
Generic Co-payment $20 30
Formulary Co-payment $40 30
Non-Formulary Co-payment $60 30
Diabetic Supplies² $0 30
Asthmatic Supplies³ $0 30
Formulary Home Delivery Program with Oral Contraceptive Coverage
Generic Co-payment $20 90
Formulary Co-payment $40 90
Non-Formulary Co-payment $60 90
Diabetic Supplies² $0 90
Asthmatic Supplies³ $0 90

¹ A formulary drug is an FDA approved prescription medication included in Medical Mutual's list of preferred Prescription Drugs.
² Includes over-the-counter items, as well as insulin, syringes and needles, glucose monitors, meters or glucowatch.
³ Includes Replacement bags, Peak Flow Meters and Inhalation Spacers only.
* Home Delivery Incentive: When a member chooses to fill a prescription a third time at a retail pharmacy within 180 days, the member will pay
   twice the normal retail copayment.

Prescription Drug Mail Order Form

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