Page 7 - Great Circle 2021 Benefits Guide
P. 7
2021
Great Circle Benefits Enrollment
Prescription Drugs
Anthem partners with Ingenio to offer prescription drug coverage to Anthem members. Similar to the medical
plan options, prescription drug coverage has in-network and out-of-network beneits. Your copayment for
prescription drugs varies depending on the type of drug used to ill your prescription.
Plan 1 Plan 2 Plan 3
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Retail
Preferred Deductible then
Generic $15 copay Not covered $15 copay Not covered $15 copay Not covered
Preferred Brand- Deductible then
Name $45 copay Not covered $45 copay Not covered $35 copay Not covered
Non-Preferred $75 copay Not covered $75 copay Not covered Deductible then Not covered
$55 copay
Specialty $100 copay Not covered $100 copay Not covered Deductible then Not covered
$100 copay
Anthem Rx Home Delivery Service
Consider signing up to have your prescription delivered to your home sometimes with a higher quantity. Mail order ofers a 90-day
supply of your prescription. Please note not all prescriptions can be mail order.
Preferred Deductible then
Generic $37.50 copay Not covered $37.50 copay Not covered $37.50 copay Not covered
Preferred Brand- Deductible then
Name $112.50 copay Not covered $112.50 copay Not covered $87.50 copay Not covered
Non-Preferred $187.50 copay Not covered $187.50 copay Not covered Deductible then Not covered
$137.50 copay
Mandatory Home Delivery Prescription Drug Notes
With the Great Circle health plan, you need to use home Specialty medications are limited up to a 30-day
delivery for any prescription medicines you take on a regular, supply regardless of whether they are retail or mail
long-term basis. Or you can get 90-day supplies of your service.
medicines from a CVS pharmacy at the same copay as home Member may be responsible for additional cost when
delivery. It’s your choice. You can get your prescriptions illed at not selecting the available generic drug.
your local pharmacy two times—the irst ill plus one reill. But Covered drugs are based on the most up-to-date
after that, you’ll have to pay the full cost for the medicines until Anthem National Drug List.
you switch to home delivery or CVS. You can make the switch
by phone or online. When you get your medicines at your local
pharmacy, Anthem will send you a letter to tell you about home
delivery, how it works and cost savings you may see.
7
Great Circle Benefits Enrollment
Prescription Drugs
Anthem partners with Ingenio to offer prescription drug coverage to Anthem members. Similar to the medical
plan options, prescription drug coverage has in-network and out-of-network beneits. Your copayment for
prescription drugs varies depending on the type of drug used to ill your prescription.
Plan 1 Plan 2 Plan 3
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Retail
Preferred Deductible then
Generic $15 copay Not covered $15 copay Not covered $15 copay Not covered
Preferred Brand- Deductible then
Name $45 copay Not covered $45 copay Not covered $35 copay Not covered
Non-Preferred $75 copay Not covered $75 copay Not covered Deductible then Not covered
$55 copay
Specialty $100 copay Not covered $100 copay Not covered Deductible then Not covered
$100 copay
Anthem Rx Home Delivery Service
Consider signing up to have your prescription delivered to your home sometimes with a higher quantity. Mail order ofers a 90-day
supply of your prescription. Please note not all prescriptions can be mail order.
Preferred Deductible then
Generic $37.50 copay Not covered $37.50 copay Not covered $37.50 copay Not covered
Preferred Brand- Deductible then
Name $112.50 copay Not covered $112.50 copay Not covered $87.50 copay Not covered
Non-Preferred $187.50 copay Not covered $187.50 copay Not covered Deductible then Not covered
$137.50 copay
Mandatory Home Delivery Prescription Drug Notes
With the Great Circle health plan, you need to use home Specialty medications are limited up to a 30-day
delivery for any prescription medicines you take on a regular, supply regardless of whether they are retail or mail
long-term basis. Or you can get 90-day supplies of your service.
medicines from a CVS pharmacy at the same copay as home Member may be responsible for additional cost when
delivery. It’s your choice. You can get your prescriptions illed at not selecting the available generic drug.
your local pharmacy two times—the irst ill plus one reill. But Covered drugs are based on the most up-to-date
after that, you’ll have to pay the full cost for the medicines until Anthem National Drug List.
you switch to home delivery or CVS. You can make the switch
by phone or online. When you get your medicines at your local
pharmacy, Anthem will send you a letter to tell you about home
delivery, how it works and cost savings you may see.
7
