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PRESCRIPTION DRUG COVERAGE COMPARISON CHART

HealthSelect of Texas Consumer Directed HealthSelect HMOs
$2,100 per individual and
$50 for each covered individual. $4,200 per family (in combined $50 for each covered individual.
Deductible
(January 1 - December 31) medical and pharmacy expenses) (September 1 - August 31)
using in-network pharmacies.
Up to a 30-day supply of Up to a 30-day supply of
Copays: Non-maintenance medications: ` Non-maintenance medications:
In-network Tier 1: $10, Tier 2: $35, Tier 3: $60 Tier 1: $10, Tier 2: $35, Tier 3: $60
Maintenance medications*: Maintenance medications*:
Copays: Copay plus 40% coinsurance for all 40% coinsurance after the annual Does not apply.
Out-of-network three tiers. out-of-network deductible is met.

Extended Days 90-day supply: 20% coinsurance after the annual Does not apply.
Supply (EDS)** Tier 1: $30, Tier 2: $105, Tier 3: $180 deductible is met.

Mail order Yes Yes Yes

Brand-name If a generic drug is available and you choose the brand-name dr ug, you will pay the Tier 1 copay or coinsurance,
drug payment as applicable, plus the difference in cost to the plan between the brand-name drug and the generic drug.
*There is a retail maintenance fee - an additional charge - for filling a 30-day supply or less of maintenance medications, which are
prescriptions you take regularly.
**An Extended Days Supply (EDS) means a pharmacy can dispense up to a 90-day supply of maintenance prescription drugs at one time.

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