Page 3 - 2015 Benefits Guide
P. 3
OPEN ENROLLMENT 2015
Blue Cross Blue Shield of Illinois Blue Cross Blue Shield of Illinois
Buy-Up Plan Basic Plan
1/1/2015 1/1/2015
Out-of-
Out-of-
Greenville PPO Network Greenville PPO Network
Prescription Drugs
Retail—34 Day Supply
Generic $15 Copay Not Covered $15 Copay Not Covered
Formulary $35 Copay Not Covered $35 Copay Not Covered
Non-Formulary $50 Copay Not Covered $60 Copay Not Covered
Mail Order—90 Day Supply
Generic $30 Copay Not Covered $30 Copay Not Covered
Formulary $70 Copay Not Covered $70 Copay Not Covered
Non-Formulary $100 Copay Not Covered $120 Copay Not Covered
Maintenance Medications through Greenville Regional Hospital—90 Day Supply
Generic $15 Copay $15 Copay
Formulary $35 Copay $35 Copay
Non-Formulary $50 Copay $60 Copay
Wellness Program
Get Rewarded for a Healthier Lifestyle
Preventive Care
z Keep up with your annual physical, dental, and vision exams
z Healthy lifestyle choices: blood pressure, cholesterol, body mass index,
smoking cessation
Engagement Snapshot
z Achieve 2,600 points to qualify for the 15% wellness discount:
December 2014
z Complete the health survey: January 2015
z Call a health coach: starting in February 2015
z Earn additional wellness points throughout the year toward
the 2,600 point goal and qualify for the 2016 discount
3
Blue Cross Blue Shield of Illinois Blue Cross Blue Shield of Illinois
Buy-Up Plan Basic Plan
1/1/2015 1/1/2015
Out-of-
Out-of-
Greenville PPO Network Greenville PPO Network
Prescription Drugs
Retail—34 Day Supply
Generic $15 Copay Not Covered $15 Copay Not Covered
Formulary $35 Copay Not Covered $35 Copay Not Covered
Non-Formulary $50 Copay Not Covered $60 Copay Not Covered
Mail Order—90 Day Supply
Generic $30 Copay Not Covered $30 Copay Not Covered
Formulary $70 Copay Not Covered $70 Copay Not Covered
Non-Formulary $100 Copay Not Covered $120 Copay Not Covered
Maintenance Medications through Greenville Regional Hospital—90 Day Supply
Generic $15 Copay $15 Copay
Formulary $35 Copay $35 Copay
Non-Formulary $50 Copay $60 Copay
Wellness Program
Get Rewarded for a Healthier Lifestyle
Preventive Care
z Keep up with your annual physical, dental, and vision exams
z Healthy lifestyle choices: blood pressure, cholesterol, body mass index,
smoking cessation
Engagement Snapshot
z Achieve 2,600 points to qualify for the 15% wellness discount:
December 2014
z Complete the health survey: January 2015
z Call a health coach: starting in February 2015
z Earn additional wellness points throughout the year toward
the 2,600 point goal and qualify for the 2016 discount
3
