Page 8 - 2018 Movilitas 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 BCBS of IL
$750 Ded PPO Copay $1,500 Ded PPO $3,000 Ded
Plan Copay Plan Qualiied HDHP
In-Network In-Network In-Network
Prescription Drugs
Deductible None Medical ded Medical ded
Out-of-Pocket Separate Rx OOP of Separate Rx Rx included in
Maximum (OOP) $500 per individual/ OOP of $500 per medical OOP on
$1,000 per family individual/$1,000 per previous page
family
Step Therapy Applies Applies Applies
Retail
Tier 1 $10 copay $10 copay, after ded 100% after ded
Tier 2 $30 copay $40 copay, after ded 100% after ded
Tier 3 $50 copay $70 copay, after ded 100% after ded
Mail Order
Tier 1 $25 copay $25 copay, after ded 100% after ded
Tier 2 $75 copay $100 copay, after ded 100% after ded
Tier 3 $125 copay $175 copay, after ded 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 BCBS of IL
$750 Ded PPO Copay $1,500 Ded PPO $3,000 Ded
Plan Copay Plan Qualiied HDHP
In-Network In-Network In-Network
Prescription Drugs
Deductible None Medical ded Medical ded
Out-of-Pocket Separate Rx OOP of Separate Rx Rx included in
Maximum (OOP) $500 per individual/ OOP of $500 per medical OOP on
$1,000 per family individual/$1,000 per previous page
family
Step Therapy Applies Applies Applies
Retail
Tier 1 $10 copay $10 copay, after ded 100% after ded
Tier 2 $30 copay $40 copay, after ded 100% after ded
Tier 3 $50 copay $70 copay, after ded 100% after ded
Mail Order
Tier 1 $25 copay $25 copay, after ded 100% after ded
Tier 2 $75 copay $100 copay, after ded 100% after ded
Tier 3 $125 copay $175 copay, after ded 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
