Active Health Plan Benefit Tabs™

This is a summary of benefits and not a substitute for the Southern California IBEW-NECA Health Plan Summary Plan Description, and to the extent it differs from the SPD, the terms of the SPD will govern.


Basic Prescriptions
 

These pharmacy benefits apply to participants in all three Active Health Programs.

This program allows you to use a participating network pharmacy for all drug purchases and you do not need a claim form. Generic drugs will always be dispensed unless you or your physician request brand name drugs. If you obtain a brand-name drug, you pay a higher copayment. In addition, you must pay for the additional ingredient cost of the brand-name drug.

Walk-in Pharmacy Benefits
 
Category Your Copay
Generic - 30 day supply
$0
Generic (maintenance drugs) - 100 day supply $0
Brand-name 30 day supply (when generic not available) $10
Brand-name (maintenance drugs) 100 day supply (when generic not available) $20
Mail Service Pharmacy Benefits for Maintenance Drugs
 
Category Your Copay
Generic - 100 day supply $0
Brand-name 100 day supply (when generic not available) $20
Non-Network Pharmacy Benefits
 

You must file a claim to be reimbursed for your drugs within 15 months of the purchase. This option is intended for emergencies or when travelling only. Reimbursement is limited by the Plan's average costs for prescriptions; you will pay for amounts over the limits in addition to the copay.

Network Pharmacy Chains
 

Albertsons, Costco, CVS (including Target Pharmacy and Longs), Horton and Converse, K-Mart Pharmacies, Medicine Shoppe, Pavilions Pharmacies, Raley's Super Stores, Ralphs, Rite Aid, Safeway Pharmacy, Save Mart Supermarkets, Sav-On Drugs, Shopko Stores, Vons/Pavilions Pharmacies, Walgreens

Limitations
 

Certain limitations apply to the following covered benefits: smoking deterrents, morning after pills & kits, and drugs to treat erectile dysfunction.

Additional Information
 

Citizens Rx
Website: http://www.citizensrx.com/member/

RX Bin# 015284
PCN: n/a

Summary of Benefits and Coverage (SBC)