Page 6 - Polyventive 2022 Benefits Guide
P. 6
Prescription Drug Plan For Bi-Weekly Employee
Medical Plan Participants Contributions
Beneit $2,500 Ded PPO $2,500 Ded PPO $3,000 Ded HSA
Description Option $3,000 Ded HSA Plan Option Plan
Prescription None Combined with Non‑ Tobacco Non‑ Tobacco
Deductible medical deductible Tobacco Tobacco
Prescription Combined with Combined with Employee $69.27 $72.04 $36.61 $38.07
Out-of-Pocket medical out-of- medical out-of- Employee +
Maximums pocket pocket Spouse $170.80 $177.63 $100.52 $104.55
Preferred Pharmacy (30-day supply) Employee +
Tier 1 $20 $10 Child(ren) $154.54 $160.72 $90.95 $94.59
Tier 2 $45 $30 Family $244.00 $253.76 $143.61 $149.35
Tier 3 $90 $60
Tier 4 $250 $250 To assist Employees in building their Health Savings
Tier 5 $500 Account (HSA), the Company will provide a one-
Retail 90-Days and/or Mail Order time deposit for the participation in the Consumer
Tier 1 $50 $25 Driven Health Plan and Health Savings Account. This
Tier 2 $112.50 $75 deposit will be made following the irst payroll after
Tier 3 $225 $150 the Employee joins these plans. The tiers for this one
90-day retail and mail time deposit are:
Tier 4/Tier 5 $500
order not available
■ Individual coverage: $500
Polyventive has a mail-order prescription drug ■ Individual + dependents: $1,000
program which will deliver a 90-day supply of
routine maintenance drugs to your home. To enroll
in the CVA Caremark Mail Service Pharmacy for the
irst time, you should request a new 90-day supply
prescription from your physician and submit it with
the mail order form available on www.aetna.com
or call 866.612.3862. Members can also receive
a 90-day supply of maintenance drugs at a retail
pharmacy; retail pharmacy copays apply. The
pharmacy network is Aetna National Network; the
formulary is Advanced Control Formulary Aetna
Insured.
6
Medical Plan Participants Contributions
Beneit $2,500 Ded PPO $2,500 Ded PPO $3,000 Ded HSA
Description Option $3,000 Ded HSA Plan Option Plan
Prescription None Combined with Non‑ Tobacco Non‑ Tobacco
Deductible medical deductible Tobacco Tobacco
Prescription Combined with Combined with Employee $69.27 $72.04 $36.61 $38.07
Out-of-Pocket medical out-of- medical out-of- Employee +
Maximums pocket pocket Spouse $170.80 $177.63 $100.52 $104.55
Preferred Pharmacy (30-day supply) Employee +
Tier 1 $20 $10 Child(ren) $154.54 $160.72 $90.95 $94.59
Tier 2 $45 $30 Family $244.00 $253.76 $143.61 $149.35
Tier 3 $90 $60
Tier 4 $250 $250 To assist Employees in building their Health Savings
Tier 5 $500 Account (HSA), the Company will provide a one-
Retail 90-Days and/or Mail Order time deposit for the participation in the Consumer
Tier 1 $50 $25 Driven Health Plan and Health Savings Account. This
Tier 2 $112.50 $75 deposit will be made following the irst payroll after
Tier 3 $225 $150 the Employee joins these plans. The tiers for this one
90-day retail and mail time deposit are:
Tier 4/Tier 5 $500
order not available
■ Individual coverage: $500
Polyventive has a mail-order prescription drug ■ Individual + dependents: $1,000
program which will deliver a 90-day supply of
routine maintenance drugs to your home. To enroll
in the CVA Caremark Mail Service Pharmacy for the
irst time, you should request a new 90-day supply
prescription from your physician and submit it with
the mail order form available on www.aetna.com
or call 866.612.3862. Members can also receive
a 90-day supply of maintenance drugs at a retail
pharmacy; retail pharmacy copays apply. The
pharmacy network is Aetna National Network; the
formulary is Advanced Control Formulary Aetna
Insured.
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