Page 10 - On Locaiton 2023 Benefit Guide
P. 10

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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