Page 7 - 2022 Thrall Benefits Guide

Pharmacy Coverage

PPO Plan Choice Fund HSA Plan
Medical Plan Provisions
In-Network Out-of-Network In-Network Out-of-Network
Prescription Drug Deductible $50/$100 $50/$100 Combined with Medical
(Individual/Family)
Prescription Drug Out-of-Pocket
Maximum $3,900/$6,800 $7,050/$12,100 Combined with Medical
(Individual/Family)
Retail Pharmacy (up to a30-day
supply) In-Network Out-of-Network In-Network Out-of-Network

Tier 1 – Generic $10 Copay 10% then Deductible
Tier 2 – Brand Preferred $40 Copay 40% after Deductible 10% then Deductible Not Covered

Tier 3 – Brand Non-Preferred $60 Copay 10% then Deductible
Mail Order Pharmacy(90-day In-Network Out-of-Network In-Network Out-of-Network
supply)
Tier 1 – Generic $20 Copay 10% then Deductible

Tier 2 – Brand Preferred $80 Copay N/A 10% then Deductible Not Covered
Tier 3 – Brand Non-Preferred $120 Copay 10% then Deductible

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