Page 7 - Great Circle 2022 Benefits Guide

2022

Benefits Guide

Prescription Drugs

Anthem partners with Ingenio to ofer 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 $37.50 copay Not covered $37.50 copay Not covered Deductible then Not covered
Generic $37.50 copay
Preferred Brand- $112.50 copay Not covered $112.50 copay Not covered Deductible then Not covered
Name $87.50 copay

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 delivery z Specialty medications are limited up to a 30-day
for any prescription medicines you take on a regular, long- supply regardless of whether they are retail or mail
term basis. Or you can get 90-day supplies of your medicines service.
from a CVS pharmacy at the same copay as home delivery. It’s
your choice. You can get your prescriptions illed at your local z Member may be responsible for additional cost when
pharmacy two times—the irst ill plus one reill. But after that, not selecting the available generic drug.
you’ll have to pay the full cost for the medicines until you switch z Covered drugs are based on the most up-to-date
to home delivery or CVS. You can make the switch by phone or Anthem National Drug List.
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.

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