Page 6 - Guide

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

Retail
Tier 1 [X] copay [X] copay [X] copay, 100% after
after ded ded
Tier 2 [X] copay [X] copay [X] copay, 100% after
after ded ded
Tier 3 [X] copay [X] copay [X] copay, 100% after
after ded ded
Mail Order
Tier 1 [X] copay [X] copay [X] copay, 100% after
after ded ded
Tier 2 [X] copay [X] copay [X] copay, 100% after
after ded ded
Tier 3 [X] copay [X] copay [X] copay, 100% after
after ded 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 .

6 2018 Benefits Enrollment