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Self-Funded Outpatient Prescription Drug Benefits For All Participants

Schedule of Outpatient Prescription Drug Benefits
	Pipe Trades PPO Plus Participants	Kaiser Participants
Lifetime Maximum Benefit	Included in $2M lifetime maximum for medical plan	$1M
YOUR PAYMENT¹
	At Retail PBM Pharmacy²	Through PBM Mail Service Pharmacy
Generic	20% of cost	20% of cost up to $20
Preferred Brand	30% of cost	30% of cost up to $50
Non - Preferred Brand	50% of cost	50% of cost up to $140
Maximum Supply	34 days	90 days

¹ Your payment is due at time of purchase. No claim form required. ² No benefit available at PBM pharmacies if you fail to show your PBM ID Card unless you have your PBM number with you.

The benefits described on this page apply only to outpatient prescription drugs which cost less than $500 per prescription, for a supply of 31 days or less. All medications costing over $500 per prescription for a supply of 31 days or less are covered through the Pipe Trades PPO Plus medical plan and subject to deductibles and coinsurance maximums (even for Kaiser members), not this outpatient prescription drug benefit, and must be Pre-Certified by the Plan and obtained through the mail service pharmacy. No coverage if Pre-Certification not obtained. See page 22.

Prescriptions obtained at non-PBM pharmacies (and outside the PBM's Mail Service Pharmacy) are not covered unless in conjunction with emergency services provided out-of-area (i.e. more than 30 miles from the nearest PBM pharmacy). Coverage is 50% of cost.