Page 8 - Guide

2017 BENEFITS ENROLLMENT

2017 Pharmacy Plan Comparison

PPO Plan
Regional One Health
Pharmacy BCBS Pharmacy Network Out-of-Network
30-Day Supply
Generic No copayment $15 $25
Preferred Brand No copayment $50 $100
Non Preferred Brand No copayment $100 $150
Specialty* No copayment $150 Not covered
Maintenance No copayment $30 $160
90-Day Supply
Generic No copayment $20 Not covered
Preferred Brand No copayment $60 Not covered
Non Preferred Brand No copayment $140 Not covered
Maintenance No copayment $40 $180
Prescription Out-of-Pocket Maximum
Prescription Out-of-Pocket N/A Included in medical Included in medical
Maximum

* Specialty Rx disclaimer—specialty medications must be illed through Regional One Health Outpatient Pharmacy

Bi-Weekly Medical and Rx Premiums

Employee Premium
Employee Only $73 .83
Employee + Spouse $187 .25
Employee + Child(ren) $139 .10
Family $219 .35

8 REGIONAL ONE HEALTH