Page 13 - Apricity Benefits Guide
P. 13
2020
Apricity Benefits Overview
PHARMACY PLAN SUMMARY
Anthem
Anthem
Anthem
Beneit Core Plan Core Plus Plan HSA Plan
Description In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Pharmacy Calendar Year Deductible
Individual None None Medical Deductible Applies First
Retail
Preferred $15 copay 50% after $10 copay 50% after 20% after 50% after
Generic deductible deductible deductible deductible
Preferred $45 copay 50% after $35 copay 50% after 20% after 50% after
Branded deductible deductible deductible deductible
Brand Name $80 copay 50% after $60 copay 50% after 20% after 50% after
Non-Preferred deductible deductible deductible deductible
Specialty 50% after 50% after 20% after 50% after
(Limited to 30- 20% to $250 deductible 20% to $200 deductible deductible deductible
day supply)
Mail Order/Retail 90
Preferred $30 copay Not covered $20 copay Not covered 20% after Not covered
Generic deductible
Preferred $90 copay Not covered $70 copay Not covered 20% after Not covered
Branded deductible
Brand Name $160 copay Not covered $120 copay Not covered 20% after Not covered
Non-Preferred deductible
This summary outlines the highlights of your plan. For a complete list of both covered and not covered services, including beneits
required by your state, see your employer’s insurance certiicate, or Summary Plan Description for the oficial plan documents. If there
are any differences between this summary and the plan documents, the information in the plan documents takes precedence.
Employees Also Have Access to the Following Pharmacy Management
Programs
Step Therapy: requires that you begin drug therapy for a medical condition with the most cost-effective, safest
drug and progress to other more costly or risky therapy, only if necessary (i.e., you must try drug “A” before you
can get drug “B”).
Prior Authorization: requires that you obtain pre-approval for certain medications in order for them to be covered
by your plan. This means if you don’t receive prior approval, the drug will not be covered at the pharmacy, and
you will have to pay the entire cost.
Retail 90: you have the option of getting a 90-day supply of any covered prescription drug, including maintenance
drugs, at participating Retail 90 pharmacies. To ind a Retail 90 pharmacy, log on to www.anthem.com and
choose “Pharmacy,” select “Find a Pharmacy” on the Pharmacy page and enter your zip code or city.
Table of Contents Your Quick Guide to Savings and Group Auto and Home Insurance .33
About Your Beneits Program. . . . . . .2 Spending Accounts .............16 Group Legal Services ............33
Beneits Basics ...................3 Dental Beneits .................18 Employee Assistance Program ....34
Medical/Prescription Drugs Beneits . 6 Dental Plan Summary ............20 Medicare Part D Creditable
Comparing Medical Plan Options ..7 Vision Beneits ..................21 Coverage Notice ...............35
First Stop Health ................11 Voluntary Disability Insurance .....22 Premium Assistance Under Medicaid
Medical Plan Summary ..........12 Life and AD&D Insurance ........25 and the Children’s Health Insurance
Program (CHIP) .................42
Pharmacy Plan Summary .........13 Voluntary Accident Insurance ....29 Contact Information .............46 13
Flexible Spending Accounts ......14 Voluntary Critical Illness Insurance . 31
Apricity Benefits Overview
PHARMACY PLAN SUMMARY
Anthem
Anthem
Anthem
Beneit Core Plan Core Plus Plan HSA Plan
Description In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Pharmacy Calendar Year Deductible
Individual None None Medical Deductible Applies First
Retail
Preferred $15 copay 50% after $10 copay 50% after 20% after 50% after
Generic deductible deductible deductible deductible
Preferred $45 copay 50% after $35 copay 50% after 20% after 50% after
Branded deductible deductible deductible deductible
Brand Name $80 copay 50% after $60 copay 50% after 20% after 50% after
Non-Preferred deductible deductible deductible deductible
Specialty 50% after 50% after 20% after 50% after
(Limited to 30- 20% to $250 deductible 20% to $200 deductible deductible deductible
day supply)
Mail Order/Retail 90
Preferred $30 copay Not covered $20 copay Not covered 20% after Not covered
Generic deductible
Preferred $90 copay Not covered $70 copay Not covered 20% after Not covered
Branded deductible
Brand Name $160 copay Not covered $120 copay Not covered 20% after Not covered
Non-Preferred deductible
This summary outlines the highlights of your plan. For a complete list of both covered and not covered services, including beneits
required by your state, see your employer’s insurance certiicate, or Summary Plan Description for the oficial plan documents. If there
are any differences between this summary and the plan documents, the information in the plan documents takes precedence.
Employees Also Have Access to the Following Pharmacy Management
Programs
Step Therapy: requires that you begin drug therapy for a medical condition with the most cost-effective, safest
drug and progress to other more costly or risky therapy, only if necessary (i.e., you must try drug “A” before you
can get drug “B”).
Prior Authorization: requires that you obtain pre-approval for certain medications in order for them to be covered
by your plan. This means if you don’t receive prior approval, the drug will not be covered at the pharmacy, and
you will have to pay the entire cost.
Retail 90: you have the option of getting a 90-day supply of any covered prescription drug, including maintenance
drugs, at participating Retail 90 pharmacies. To ind a Retail 90 pharmacy, log on to www.anthem.com and
choose “Pharmacy,” select “Find a Pharmacy” on the Pharmacy page and enter your zip code or city.
Table of Contents Your Quick Guide to Savings and Group Auto and Home Insurance .33
About Your Beneits Program. . . . . . .2 Spending Accounts .............16 Group Legal Services ............33
Beneits Basics ...................3 Dental Beneits .................18 Employee Assistance Program ....34
Medical/Prescription Drugs Beneits . 6 Dental Plan Summary ............20 Medicare Part D Creditable
Comparing Medical Plan Options ..7 Vision Beneits ..................21 Coverage Notice ...............35
First Stop Health ................11 Voluntary Disability Insurance .....22 Premium Assistance Under Medicaid
Medical Plan Summary ..........12 Life and AD&D Insurance ........25 and the Children’s Health Insurance
Program (CHIP) .................42
Pharmacy Plan Summary .........13 Voluntary Accident Insurance ....29 Contact Information .............46 13
Flexible Spending Accounts ......14 Voluntary Critical Illness Insurance . 31
