Page 5 - 2017-18 Centennial Benefits Guide Staff
P. 5
QHDHP $1,500 QHDHP $2,600
In-Network Out-of-Network In-Network Out-of-Network
Deductible/80% Deductible/60% Deductible/80% Deductible/60%
Prescription Drugs
Retail (up to 31-day supply)
Tier 1 $10 copay after medical $10 copay after medical
deductible In-Network copay plus deductible In-Network copay
plus cost difference
Tier 2 $30 copay after medical cost difference between $30 copay after medical between network and
deductible network and non-network deductible non-network pharmacy
Tier 3 $50 copay after medical pharmacy after deductible $50 copay after medical after deductible
deductible deductible
Mail Order (up to 90-day supply)
Tier 1 $25 copay after medical $25 copay after medical
deductible deductible
Tier 2 $75 copay after medical Not covered $75 copay after medical Not covered
deductible deductible
Tier 3 $125 copay after medical $125 copay after medical
deductible deductible
1 If family (employee plus one or more dependents) coverage is elected, the individual deductible does not apply .
2 If family (employee plus one or more dependents) coverage is elected, the individual out-of-pocket maximum does not apply.
3 Once the family deductible is met, all family members will be considered having met their deductible for the remainder of the calendar year . No one
family member may contribute more than the individual deductible amount to the family deductible .
4 Once the family maximum out-of-pocket limit is met, all family members will be considered having met their maximum out-of-pocket limit for the
remainder of the calendar year. No one family member may contribute more than the individual maximum out-of-pocket limit amount to the family
maximum out-of-pocket limit. The out-of-pocket limit includes all copays, deductibles, and coinsurance.
Centennial Contractors 5
In-Network Out-of-Network In-Network Out-of-Network
Deductible/80% Deductible/60% Deductible/80% Deductible/60%
Prescription Drugs
Retail (up to 31-day supply)
Tier 1 $10 copay after medical $10 copay after medical
deductible In-Network copay plus deductible In-Network copay
plus cost difference
Tier 2 $30 copay after medical cost difference between $30 copay after medical between network and
deductible network and non-network deductible non-network pharmacy
Tier 3 $50 copay after medical pharmacy after deductible $50 copay after medical after deductible
deductible deductible
Mail Order (up to 90-day supply)
Tier 1 $25 copay after medical $25 copay after medical
deductible deductible
Tier 2 $75 copay after medical Not covered $75 copay after medical Not covered
deductible deductible
Tier 3 $125 copay after medical $125 copay after medical
deductible deductible
1 If family (employee plus one or more dependents) coverage is elected, the individual deductible does not apply .
2 If family (employee plus one or more dependents) coverage is elected, the individual out-of-pocket maximum does not apply.
3 Once the family deductible is met, all family members will be considered having met their deductible for the remainder of the calendar year . No one
family member may contribute more than the individual deductible amount to the family deductible .
4 Once the family maximum out-of-pocket limit is met, all family members will be considered having met their maximum out-of-pocket limit for the
remainder of the calendar year. No one family member may contribute more than the individual maximum out-of-pocket limit amount to the family
maximum out-of-pocket limit. The out-of-pocket limit includes all copays, deductibles, and coinsurance.
Centennial Contractors 5
