Prescription Drug Coverage |
|
|
Retail 30 Day Suppy |
Mail Order 90 Day Supply |
PPO 4 |
Generic |
$10 Copay |
$20 Copay |
Preferred Brand |
$25 Copay |
$50 Copay |
Non-Preferred Brand |
50% Coinsurance |
50% Coinsurance |
Specialty |
$200 Copay |
Not Available |
HDHP 3 |
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 |
HDHP 4 |
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 |
HDHP 6 |
Generic |
30% Coinsurance after Deductible |
30% Coinsurance after Deductible |
Preferred Brand |
30% Coinsurance after Deductible |
30% Coinsurance after Deductible |
Non-Preferred Brand |
30% Coinsurance after Deductible |
30% Coinsurance after Deductible |
Specialty |
30% Coinsurance after Deductible |
Not Available |