RxBenefits Plan 3 - Prescription Drug Cost Share and Coverage Terms

Sep 17, 2026

North Central Indiana School Trust RxBenefits plan details member cost share for prescription and medical claims effective October 1, 2020, including 30-day and 90-day supply and retail/specialty copay tiers for generic, preferred brand, and non-preferred brand drugs. It specifies individual and family calendar-year deductible and maximum out-of-pocket (MOOP) requirements, payment at 100% once met, and how dispense as written affects MOOP and deductible. It also covers specialty medication ordering rules, prior authorization triggers, and key covered drug categories with exclusions and member service contact information.

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Effective October 1, 2020

30 Day Supply, 90 Day Supply, and Retail/Specialty Tiers

Deductible and Maximum Out of Pocket (MOOP)

Dispense As Written Policy

Specialty Medications and Prior Authorization

Covered Drugs and Exclusions

North Central Indiana School TrustEffective October 1,2020 30 Day Supply 90 Day Supply Retail/Speciaity* Mail $20 $40 Tler1-Generic Drugs $80 $40 Tier 2-Preferred Brand Name Drugs Tler 3-Non-Preferred Brand Name Drugs $80 $160 Maximum Out of Pocket(MOOP):$2,600 Indivldual/$5,200 Family The calendar year MOOPapplies to pharmacy claims.Each individual family member must meet the single MOOP unless thefamily MOOP has been met by any two or more covered family members.Once met,your covered prescriptions are paid at100%.Generic dispense as written penalties do not apply to the MOOP. Plan 3 Deductible:$3,000 Individual/$6,000 Family The calendar year deductible applies to pharmacy and medical claims.Each individual family member must meet theindividual deductible unless the family deductible has been met by any two or more covered family members.Once met,your covered prescriptions are paid at 100%.Dispense as written penalties do not apply to the deductible.The deductibledoes apply to the Maximum Out of Pocket(MOOP). 30 Day Supply90 Day SupplyRetail/specialty"5oTier 1-Generic Drugs0Tier 2-Preferred Brand Name DrugsS0Tier 3-Non-Preferred Brand Name Drugs$O Maximum Out of Pocket(MOOP):$3,000 Individual/$6,000 Family The calendar year Maximum Out of Pocket(MOOP)applies to pharmacy and medical.Each individual family member must meetthe individual MOOP unless the family MOOP has been met by any two or more covered family members.Once met,yourcovered prescriptions are paid at 100%. Plan 4 Deductible:$6,000 Individual/$12,000 Family The calendar year deductible applies to pharmacy and medical claims.Each individual family member must meet theindividual deductible unless the family deductible has been met by any two or more covered family members.Once met,your covered prescriptions are paid at 100%.Dispense as written penalties do not apply to the deductible.The deductibledoes apply to the Maximum Out of Pocket(MOOP). 30 Day Supply90 Day Supplye5alTier 1-Generic Drugs Tler 2-Preferred Brand Name Drugs50Tler 3-Non-Preferred Brand Name Drugs$o Maximum Out of Pocket(MOOP):$6,000 Individual/$12,000 Family The calendar year Maximum Out of Pocket(MOOP)applies to pharmacy and medical.Each individual familymember must meetthe individual MOOP unless the family MOOP has been met by any two or more covered family members.Once met,yourcovered prescriptions are paid at 100% For Prescription Drug Card Member Services Call RxBenefits at 1-800-334-8134 *Specialty Medications:Specialty medications are limited to 30 day supply and are subject to retail copays.Specialtymedications must be ordered from Accredo Specialty Pharmacy at 1-800-803-2523 and may be subject to prior authorization,step therapy,and quantity limits. Dispense As Written Policy:If your doctor writes a prescription stating that a generic may be dispensed,we will only payfor the generic drug.If you choose to buy the brand name drug in this situation,you will be required to pay the brandcopay plus the difference in cost between the generic and brand name drug.The Dispense As Written Policy does not applyif your doctor requires a brand name medication. Medication costs exceeding $1,000 per 30 day supply and $3,000 per90 day supply require prior authorization. Some medications may require clinical prior authorization.If your medication requires a prior authorization,please contact1-888-608-8851. # DRUGS COVERED* ·Legend Drugs(drugs that require a prescription)Exceptions:See Exclusion list below · Compound medications of which at least one ingredient is a legend drug at a participating pharmacy.Compoundedmedications equal to or exceeding $300 per script may require prior authorization. · Diabetic Care:Insulin/Insulin pre-filled syringes,Agents/Strips for testing,Disposable insulin needles/syringes andlancets · Contraceptives:Oral,transdermal,intravaginal,implantable devices,injectable

FAQs

What does the calendar-year MOOP apply to, and how is it met for individuals and families?

The calendar-year MOOPapplies to pharmacy claims. Each individual family member must meet the single MOOP unless the family MOOP has been met by any two or more covered family members.

How does the deductible work for Plan 3?

The calendar-year deductible applies to pharmacy and medical claims. Each individual must meet the individual deductible unless the family deductible has been met by any two or more covered family members, after which covered prescriptions are paid at 100%.

When do medications require prior authorization and how is it handled?

Medication costs exceeding $1,000 per 30-day supply and $3,000 per 90-day supply require prior authorization. Some medications may also require clinical prior authorization, and members should contact the listed RxBenefits number.

Sep 17, 2026

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