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by Keith Jeter

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<div class="panel-body panel-scroll-fit"><span id="manualTagEnd19"></span> <b>Note:</b> Your prescription drug copays and coinsurance amounts, including mail order copay and coinsurance amounts, are subject to the <b>same</b> annual out-of-pocket maximum required under your medical coverage. The following prescription drug expenses will not apply to your annual out-of-pocket maximum. <ul>
    <li>any difference between the Maximum Allowable Cost and BCBSM's approved amount for a covered brand-name drug</li>
    <li>the 25% member liability for covered drugs obtained from an out-of-network pharmacy</li>
  </ul> <br><b>Note: </b>If your prescription is filled by any type of in-network pharmacy, and you request the brand-name drug when a generic equivalent is available on the BCBSM MAC list and the prescriber HSA not indicated "Dispensed as Written" (DAW) on the prescription, you must pay the difference in cost between the brand-name drug dispensed and the maximum allowable cost for the generic <b>plus </b>the applicable copay/coinsurance. <table>
    <thead>
      <tr>
        <th class="col1rx30" colspan="2"><b>Benefits</b></th>
        <th class="col2rx">90-day retail network pharmacy</th>
        <th class="col2rx">* In-network mail order provider</th>
        <th class="col2rx">In-network pharmacy (not part of the 90-day retail network)</th>
        <th class="col3rx">Out-of-network pharmacy</th>
      </tr>
    </thead>
    <tbody> </tbody>
    <tbody>
      <tr>
        <td class="col1rx30" style="border-bottom:none">Tier 1 - Generic or select prescribed over-the-counter drugs <ul> </ul>
        </td>
        <td class="col1rx">1 to 30-day period</td>
        <td class="col2rx"> You pay $10 copay <ul> </ul>
        </td>
        <td class="col3rx"> You pay $10 copay <ul> </ul>
        </td>
        <td class="col2rx"> You pay $10 copay <ul> </ul>
        </td>
        <td class="col3rx"> You pay $10 copay plus an additional 25% of BCBSM approved amount for...