Page 7 - 2022 Arabella Advisors Benefit Guide

Prescription Drug Coverage – Benefits

CVS/Caremark is the prescription drug benefits administrator for
both plans

Plan Provisions PPO Medical HRA Plan PPO Medical HSA Plan

In- Out-of- In- Out-of-
Network Network Network Network

❖ Retail Prescription Drugs (34-day supply) *

◼ $5 copay after
◼ Generic ◼ $5 copay Not covered Not covered
deductible

◼ $30 copay after
◼ Brand Preferred ◼ $30 copay Not covered Not covered
deductible

◼ $50 copay after
◼ Brand Non-preferred ◼ $50 copay Not covered Not covered
deductible

❖ Mail Order Prescription Drugs (90-day supply)

◼ $10 copay after
◼ Generic ◼ $10 copay Not covered Not covered
deductible

◼ $60 copay after
◼ Brand Preferred ◼ $60 copay Not covered Not covered
deductible

◼ $100 copay after
◼ Brand Non-preferred ◼ $100 copay Not covered Not covered
deductible

◼ $100 copay after
◼ Specialty Drugs ◼ $100 copay Not covered Not covered
deductible

* If you or your physician request a brand name drug when a generic drug is available, you will be
responsible for the brand copay plus the difference in cost.

Note: This is a summary of your coverage only. Please refer to your summary plan description for the full
scope of coverage.

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