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Pharmacy Coverage for UC Irvine

Network
Out-of-Network
SHC OptumRx and Participating UC Pharmacies All Other Pharmacies
SEPARATE ANNUAL LIMITS ON YOUR OUT-OF-POCKET COSTS $2,000/individual; $4,000/family $3,000/individual; $6,000/family $6,000/individual; $12,000/family
Your share of prescription drug costs counts toward the combined annual medical/pharmacy annual out-of-pocket limit shown above.
UC SHIP Covers

Outpatient Prescription Drugs

  • 100% after $5 generic copay
  • 100% after $25 brand-name formulary copay, 30-day supply
  • 100% after $40 brand-name non-formulary copay, 30-day supply
  • 100% after $10 generic copay
  • 100% after $35 brand-name formulary copay, 30-day supply
  • 100% after $50 brand-name non-formulary copay, 30-day supply
  • $10 generic copay
  • $35 brand-name formulary copay, 30-day supply
  • $50 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.