Page 8 - 2018 Peak Benefit Guide
P. 8
Prescription Drugs
Similar to the medical plan, the prescription drug plan has in-network and
out-of-network beneits. The participating pharmacy network includes
large drug store chains such as Walgreens, as well as many independent
pharmacies. Your copayment for prescription drugs varies depending on
the type of drug used to ill your prescription.
BCBS of IL BCBS of IL
$1,500 Ded PPO Copay Plan $3,000 Ded Qualiied HDHP
In-Network In-Network
Prescription Drugs
Deductible None Medical ded
Out-of-Pocket Maximum Separate Rx OOP of $500 Rx included in medical OOP
(OOP) per individual/ on previous page
$1,000 per family
Step Therapy Applies Applies
Retail
Tier 1 $10 copay 100% after ded
Tier 2 $40 copay 100% after ded
Tier 3 $70 copay 100% after ded
Mail Order
Tier 1 $25 copay 100% after ded
Tier 2 $100 copay 100% after ded
Tier 3 $175 copay 100% after ded
Please note: for the HSA qualiied plan, all prescription drug expenses are
subject to the medical deductible. Once you meet your deductible, copays, or
coinsurance will apply .
8 2018 Benefits Enrollment
Similar to the medical plan, the prescription drug plan has in-network and
out-of-network beneits. The participating pharmacy network includes
large drug store chains such as Walgreens, as well as many independent
pharmacies. Your copayment for prescription drugs varies depending on
the type of drug used to ill your prescription.
BCBS of IL BCBS of IL
$1,500 Ded PPO Copay Plan $3,000 Ded Qualiied HDHP
In-Network In-Network
Prescription Drugs
Deductible None Medical ded
Out-of-Pocket Maximum Separate Rx OOP of $500 Rx included in medical OOP
(OOP) per individual/ on previous page
$1,000 per family
Step Therapy Applies Applies
Retail
Tier 1 $10 copay 100% after ded
Tier 2 $40 copay 100% after ded
Tier 3 $70 copay 100% after ded
Mail Order
Tier 1 $25 copay 100% after ded
Tier 2 $100 copay 100% after ded
Tier 3 $175 copay 100% after ded
Please note: for the HSA qualiied plan, all prescription drug expenses are
subject to the medical deductible. Once you meet your deductible, copays, or
coinsurance will apply .
8 2018 Benefits Enrollment
