The member pays the pharmacy dispensing fee plus the pharmacy markup for eligible drugs. Some prescription drugs require prior authorization. Prior authorization is a claims management feature applied to some medications to determine eligibility based upon clinical criteria or cost effectiveness. The plan pays for 100% of the ingredient cost of eligible drugs, subject to policy maximums as follows:

• Coverage is limited to drugs which legally require a written prescription in order to be dispensed including seras, injectables, and oral contraceptives. Prescription by law smoking cessation drugs are subject to a maximum lifetime payment of $500 per insured member.
• Drugs used in the treatment of sexual dysfunction are subject to a maximum of $500 per person per calendar year. Anti-Obesity drugs are subject to a $4,000 calendar year maximum per insured. Fertility drugs are subject to a lifetime maximum of $15,000 per insured member. The entire Health Insurance program has a $250,000 Calendar Year Maximum per insured life in the program.
• Whenever an interchangeable generic product is available, but not dispensed, eligible expenses shall be limited to the cost of the lowest priced generic substitute.
• Life sustaining drugs of a non-prescription nature when prescribed by a physician or dentist, and dispensed by a pharmacist, physician or dentist may be eligible for coverage.
• Drugs and medically required supplies of a non-prescription nature required as a result of a colostomy and/or for the treatment of cystic fibrosis, diabetes, and parkinsonism may be eligible for coverage.