2023 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 48
PRESCRIPTION DRUG SCHEDULE OF BENEFITS
BENEFIT DESCRIPTION
BENEFIT
NOTE: There is no coverage under the Medical Plan for Prescription Drugs obtained from a
Non- Participating Provider.
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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