COVENTRY HEALTH AND LIFE INSURANCE COMPANY
(Maryland)
2751 Centerville Road, Suite 400
Wilmington, DE 19808-1627
PRESCRIPTION DRUG RIDER SCHEDULE OF MEMBER PAYMENTS
$200 - $10/$20/$45 Copayments
This Schedule of Member Payments is part of Prescription Drug Rider but does not replace it. This Rider
and your Certificate of Insurance contain complete definitions, limitations and exclusions. Reading this
Schedule by itself could give You an inaccurate impression of the terms of Your Prescription Drug
Coverage. This Schedule must be read with the Prescription Drug Rider and your Certificate of Insurance.
The Member’s financial responsibility is as follows:
Pharmacy Deductible per Individual: ................................................................................ $200
Copayments and Coinsurance
Copayments and Coinsurance for Prescription Drugs dispensed by a Participating retail, Mail Order, or
Specialty Pharmacy or Non-Participating Pharmacy are as follows:
When You Use a
Participating
Pharmacy (or a NonParticipating Pharmacy
for Emergency Drug
Prescriptions)
Formulary Generic Drug per Prescription
Order or Refill
•
Non-Maintenance
$10 Copayment
•
$20 Copayment
Maintenance – up to a 90-day supply
Formulary Brand Name Drug per
Prescription Order or Refill
•
Non-Maintenance
$20 Copayment
•
$40 Copayment
Maintenance – up to a 90-day supply
Non-Formulary Drug per Prescription
Order or Refill
•
Non-Maintenance
$45 Copayment
•
$90 Copayment
Maintenance – up to a 90-day supply
When You Use a
Non-Participating
Pharmacy for NonEmergency Drug
Prescriptions
$10 Copayment, then
20% Coinsurance
$20 Copayment, then
20% Coinsurance
$20 Copayment, then
20% Coinsurance
$40 Copayment, then
20% Coinsurance
$45 Copayment, then
20% Coinsurance
$90 Copayment, then
20% Coinsurance
Annual Maximum ...............................................................................................................None
CHL(MD) 911.1
1 of 2
1/05
LG PPO $200 Ded - $10/20/45
CHDE 3810M
Rx 45055
PLEASE NOTE THAT IF YOU RECEIVE SERVICES FROM AN OUT-OF-NETWORK PROVIDER, YOUR
COINSURANCE AMOUNT WILL BE APPLIED TO THE OUT-OF-NETWORK RATE TO DETERMINE HOW
MUCH WE PAY FOR COVERED SERVICES PROVIDED BY THE OUT-OF-NETWORK PROVIDER. Based on
your benefit plan, You may have limited coverage for out-of-network services. Please review your certificate of
insurance carefully regarding when out-of-network services may be included in your coverage.
Out-of-Network Rate: The maximum amount covered by Us for approved out-of-network services. This rate will
be derived from either a Medicare based fee schedule or a percent of billed charges as determined by Us, based
on the following:
•
Non-Participating Physicians Fees. The Out-of-Network Rate is equivalent to a percentage of the
2002 Medicare RBRVS fee schedule for physician charges. The fee schedule shall be based upon the
geographic area in which the Health Plan offers coverage and not upon the location of the provider. If
the 2002 Medicare RBRVS fee schedule does not contain a reimbursement level for a specific code,
St. Anthony’s RBRVS will be used in its place. For CPT codes developed after 2002 Medicare
RBRVS fee schedule, the Health Plan shall assign a reimbursement valuation on an annual basis
consistent with the percentage methodology described. If none of the above procedures yields a
corresponding RBRVS rate for a particular service, the Health Plan shall pay 50% of billed charges.
Non-Participating Facility Fees. The Out-of-Network Rate is equivalent to a percentage of the Medicare
reimbursement schedule for facility charges. Inpatient rates shall be set according to then-current DRG’s
(“Diagnosis Related Group”). Outpatient services will be paid at either a percentage of the then-current Medicare
reimbursement schedule for ASC’s (“Ambulatory Surgical Centers”) or at 60% of billed charges.
This is not a contract or a definitive statement of benefits. It is intended solely to provide you with an overview of
the proposed Coventry benefits. Complete details of benefits, terms and exclusions are governed by your
Coventry Pharmacy Rider. The Coventry Pharmacy Rider may not cover all your health care expenses.
Read your Coventry Pharmacy Rider carefully to determine which health care services are covered. If you
have questions call us toll free at 1-800-833-7423.
CHL(MD) 911.1
2 of 2
1/05
LG PPO $200 Ded - $10/20/45
CHDE 3810M
Rx 45055