Page 6 - 2018-19 US Tool Benefit Guide

2018–19 Benefits Enrollment

PRESCRIPTION DRUGS
Important Note
The prescription drug Similar to the medical plan, the prescription drug plan has in-network and
coverage is moving to out-of-network beneits. The participating pharmacy network includes
CVS Caremark. Please large drug store chains such as Walgreens and CVS, as well as many
review the formulary
list to confirm your independent pharmacies. Your copayment for prescription drugs varies
medication will continue depending on the type of drug used to ill your prescription.
to be covered in the
same tier level. If it
is not, refer to the CVS/Caremark
formulary list for lower Premier Plan Basic Plan
cost alternatives for In-Network Out-of-Network In-Network Out-of-Network
your medication.
Prescription Drugs
Retail—30 Days
Tier 1 $10 copay $60 or 50% $10 copay $60 or 50%
coinsurance, coinsurance,
whichever is whichever is
greater greater
Tier 2 $30 copay $60 or 50% $30 copay $60 or 50%
coinsurance, coinsurance,
whichever is whichever is
greater greater
Tier 3 $45 copay $60 or 50% $45 copay $60 or 50%
coinsurance, coinsurance,
whichever is whichever is
greater greater
Tier 4 20% up to $150 $60 or 50% 20% up to $150 $60 or 50%
coinsurance, coinsurance,
whichever is whichever is
greater greater
Mail Order–90 Days
Tier 1 $20 copay Not covered $20 copay Not covered
Tier 2 $60 copay Not covered $60 copay Not covered
Tier 3 $90 copay Not covered $90 copay Not covered
Tier 4 20% up to $150 Not covered 20% up to $150 Not covered

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