Page 10 - Impact XM 2022 Benefit Guide

Prescription Coverage

The plans provide coverage for generic drugs, brand name drugs on a formulary, and brand name drugs not
listed on the formulary.

Drug Tier Horizon BCBS Design 3 & 4 Horizon BCBS HDHP Design 13

Generic Drugs $20 $20

Brand Name Drugs – Formulary $40 $40
Brand Name Drugs – Non Formulary $70 $60
Mail Order (90 day supply) 2x Retail copay 2x Retail copay

If you are taking any maintenance medications, it’s beneficial to fill a 90 day prescription through the Mail
Order service; you will save a copay every 3 months since you only pay 2 copays for a 90 day supply of
medicine! To get setup with Mail Order, you may call the 24 hour customer service number listed on the back
of your ID card. You will need to mail your completed Mail Order form in with your prescription and applicable
payment. Within a couple of weeks, you will be setup in the system and then able to later request refills either
online or over the phone.

How do I find a participating location?

You can access Horizon’s website to search for providers in the network.

EyeMed Voluntary Vision Plan

The vision plan provided by EyeMed includes discounts on exams (including contact lens
exams) and the purchase of eyeglass, sunglasses, and other prescription eyewear when
provided by participating providers.

To find a participating doctor access www.eyemedvisioncare.com

Benefit Feature In-Network Out-of-Network Reimbursement

Routine Eye Exam $10 copay Up to $40
Every 12 months
Frames / Glasses Up to $130 Allowance; 20% off amount Up to $91
Every 24 months over balance
Lenses $25 Copay Between $30 - $70 reimbursement
Every 12 months
Single, lined bifocal, lined trifocal
Contact Lenses Every 12 months Up to $130 Allowance, 15% off amount Up to $130
(fitting and evaluation) over balance Medically Necessary: $210
Medically Necessary: Paid-in-Full

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