Page 6 - 2015 Enrollment Guide

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Comparing Your 2015 Prescription Drug Benefits
Comparing Your 2015 Prescription Drug Benefits
CIGNA CHOICE FUND CIGNA CHOICE FUND KAISER HMO
OPEN ACCESS PLUS HRA OPEN ACCESS PLUS HSA (For Associates in
(Health Reimbursement Arrangement) (Health Savings Account) GA/VA/DC/MD)
PLAN FEATURE IN-NETWORK BENEFITS IN-NETWORK BENEFITS IN-NETWORK ONLY
BENEFITS
Retail Network Pharmacy (30 day supply)

Generic Rx 20%, No Deductible (Min $0, Max $10) 20% after deductible $10 copay
Preferred Brand Rx 20%, No Deductible (Min $20, Max $40) 20% after deductible $25 copay
Non-Preferred Brand Rx 20%, No Deductible (Min $40, Max $80) 20% after deductible $35 copay
Specialty Rx 20%, No Deductible (Min $90, Max $120) 20% after deductible $35 copay

Home Delivery Pharmacy (90 day supply)
Generic Rx 2x Retail (Min $0, Max $20) 3x Retail $20 copay
Preferred Brand Rx 2x Retail (Min $40, Max $80) 3x Retail $50 copay
Non-Preferred Brand Rx 2x Retail (Min $80, Max $160) 3x Retail $70 copay

Specialty Rx 2x Retail (Min $180, Max $240) 3x Retail $70 copay