SSMC Employee Health Benefit Plan
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Please Note
Currently, the Plan requires you to pay a Copayment for a brand name prescription or refill when a
generic equivalent is available for that brand name.
4. When Another Plan is Primary. If another health plan is considered primary coverage according to the
COB order of benefit determination, you must obtain prescription benefits through that plan first, then file
a claim with EHS. Claim forms are available at the SSMC Human Resources Department. See Section I -
Summary of Benefits. Benefits will be coordinated according to secondary payer rules shown later in
Section VII - Coordination of Benefits (COB). If this Plan is secondary, do not present your SSMC
identification card at the Pharmacy nor use the Mail Service Pharmacy.
5. Participating Pharmacy. A participating Pharmacy has an agreement with the prescription drug Claims
Administrator, EHS to accept the Plan benefit, after any applicable Copayment, as payment in full. If this
Plan is the primary coverage, you or your Dependents may purchase Covered drugs at EHS Participating
Pharmacies. You will be required to pay only the following Copayments:
a. Network Copayments :
Brand Name
With generic equivalent:
$ 7.00 per each prescription or refill.
With no generic equivalent:
No Copayment. Plan pays 100% of Network allowance
Generic equivalent:
No Copayment. Plan pays 100% of Network allowance.
b. Plan Identification Card. You can use your Plan identification card at any EHS participating
(Network) Pharmacy. The Pharmacy may display the EHS participation logo or you may ask the
Pharmacy if it participates as an EHS Network Pharmacy. You can also phone EHS for participating
Pharmacies near you.
c. Obtaining Network Benefits. To obtain your Covered drug or supply at Network cost, you need only
present your Plan identification card and the written prescription to the EHS Network pharmacist, then
pay the applicable Copayment amount. The Pharmacy will bill EHS directly and will receive direct
payment from them. If you do not present your Plan identification card at the time of purchase, you
must file your own claim and benefits will be allowed as if the drug was purchased at a
nonparticipating Pharmacy. Refer to Nonparticipating Pharmacy shown later in this section.
Questions or concerns about the Network drug program can be answered by EHS. You may contact them
by calling their customer service department during normal operating hours or send a written inquiry.
Eckerd Health Services
620 Epsilon Drive
Pittsburgh, PA 5238-2845
Phone: Toll-free: 1 -888-645-9303
6. Nonparticipating Pharmacy (Out-of-Network). If this Plan is primary and you or your Dependents
purchase covered drugs at a Nonparticipating Pharmacy (or do not use your Plan identification card), you
must pay the Pharmacy and submit a claim for benefits to EHS. Allowable Fees are based on the Usual,
Customary and Reasonable Charges (UCR) for the covered drugs. Benefits are based on Allowable Fees
less the generic or brand name Copayment shown above. You will be responsible for payment of charges
more that the UCR allowance. To file a claim for benefits, you must obtain a drug claim form from your
Participating School healthcare clerk or from EHS. The original drug receipt (receipt should include dates
of purchase, names of drug, dose and Rx #.) and the completed drug claim form should be mailed to:
Eckerd Health Services
620 Epsilon Drive
Pittsburgh, PA 5238-2845
