Page 8 - Enrollment Guide Example
P. 8
2016 Benefits Enrollment
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 and CVS, as well as many
independent pharmacies. Your copayment for prescription drugs varies
depending on the type of drug used to ill your prescription.
[Carrier] [Carrier] [Carrier] [Carrier]
[Plan 1] [Plan 2] [Plan 3] [Plan 4]
In-Network In-Network In-Network In-Network
Prescription Drugs
Deductible None None Medical ded Medical ded
Out-of-pocket Separate Rx Separate Rx Rx included in Rx included in
maximum OOP of $500 OOP of $500 medical OOP medical OOP
(OOP) per individual/ per individual/ on previous on previous
$1,000 per $1,000 per page page
family family
Step therapy Applies Applies Applies Applies
Retail
Tier 1 $10 copay $10 copay $10 copay, 100% after ded
after ded
Tier 2 $30 copay $40 copay $30 copay, 100% after ded
after ded
Tier 3 $50 copay $70 copay $50 copay, 100% after ded
after ded
Mail Order
Tier 1 $25 copay $25 copay $25 copay, 100% after ded
after ded
Tier 2 $75 copay $100 copay $75 copay, 100% after ded
after ded
Tier 3 $125 copay $175 copay $125 copay, 100% after ded
after ded
Please note: for the HSA qualiied plans, all prescription drug expenses are
subject to the medical deductible. Once you meet your deductible, copays or
coinsurance will apply.
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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 and CVS, as well as many
independent pharmacies. Your copayment for prescription drugs varies
depending on the type of drug used to ill your prescription.
[Carrier] [Carrier] [Carrier] [Carrier]
[Plan 1] [Plan 2] [Plan 3] [Plan 4]
In-Network In-Network In-Network In-Network
Prescription Drugs
Deductible None None Medical ded Medical ded
Out-of-pocket Separate Rx Separate Rx Rx included in Rx included in
maximum OOP of $500 OOP of $500 medical OOP medical OOP
(OOP) per individual/ per individual/ on previous on previous
$1,000 per $1,000 per page page
family family
Step therapy Applies Applies Applies Applies
Retail
Tier 1 $10 copay $10 copay $10 copay, 100% after ded
after ded
Tier 2 $30 copay $40 copay $30 copay, 100% after ded
after ded
Tier 3 $50 copay $70 copay $50 copay, 100% after ded
after ded
Mail Order
Tier 1 $25 copay $25 copay $25 copay, 100% after ded
after ded
Tier 2 $75 copay $100 copay $75 copay, 100% after ded
after ded
Tier 3 $125 copay $175 copay $125 copay, 100% after ded
after ded
Please note: for the HSA qualiied plans, all prescription drug expenses are
subject to the medical deductible. Once you meet your deductible, copays or
coinsurance will apply.
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