Prescription Drug Coverage |
|
|
Retail 30 Day Suppy |
Mail Order 90 Day Supply |
PPO 2 Plan |
Generic |
$10 Copay |
$20 Copay |
Preferred Brand |
$25 Copay |
$50 Copay |
Non-Preferred Brand |
50% Coinsurance |
50% Coinsurance |
Specialty |
$200 Copay |
Not Available |
PPO 5 Plan |
Generic |
$10 Copay |
$20 Copay |
Preferred Brand |
$25 Copay |
$50 Copay |
Non-Preferred Brand |
50% Coinsurance |
50% Coinsurance |
Specialty |
$200 Copay |
Not Available |
HSA 1 Plan |
Generic |
$10 Copay after Deductible |
$20 Copay after Deductible |
Preferred Brand |
$25 Copay after Deductible |
$50 Copay after Deductible |
Non-Preferred Brand |
50% Coinsurance after Deductible |
50% Coinsurance after Deductible |
Specialty |
$200 Copay after Deductible |
Not Available |
Expanded Preventative |
Applicable copay above, no Deductible |
Applicable copay above, no Deductible |
HSA 2 |
Generic |
20% Coinsurance after Deductible |
20% Coinsurance after Deductible |
Preferred Brand |
20% Coinsurance after Deductible |
20% Coinsurance after Deductible |
Non-Preferred Brand |
50% Coinsurance after Deductible |
50% Coinsurance after Deductible |
Specialty |
20% Coinsurance after Deductible |
Not Available |
Expanded Preventative |
Applicable coinsurance above, no Deductible |
Applicable coinsurance above, no Deductible |