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Pharmacy Coverage for UC Davis

Network
Out-of-Network
 SHC, Participating UC Pharmacies and other OptumRx Pharmacies All Other Pharmacies
$3,400/individual; $6,800/family $6,000/individual; $12,000/family
SEPARATE LIMITS ON YOUR OUT-OF-POCKET COSTS
Your share of prescription drug costs counts toward the combined annual medical/pharmacy out-of-pocket limit listed above, with one exception: SHC pharmacy costs count toward the lower UC Family annual out-of-pocket limit—offering you additional savings.
UC SHIP Covers

Outpatient Prescription Drugs

All other covered prescription drugs:
For a 30-day supply

  • 100% after $5 generic copay
  • 100% after $15 brand-name formulary copay, 30-day supply
  • 100% after $40 brand-name non-formulary copay, 30-day supply

For a 30-day supply

  • $5 generic copay
  • $25 brand-name formulary copay, 30-day supply
  • $40 brand-name non-formulary copay, 30-day supply

You pay any amount above the OptumRx maximum allowed amount.
 
Note: 100% with no copay for FDA-approved generic and brand-name (when no generic equivalent is available). Oral contraceptives are covered for up to 180-day supply.