Page 3 - 2016 Enrollment
P. 3
Open Enrollment 2016
Blue Cross Blue Shield of Illinois Blue Cross Blue Shield of Illinois
Buy-Up Plan Basic Plan
1/1/2016 1/1/2016
Greenville PPO Out-of-Network Greenville PPO Out-of-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
Keep up with your annual physical, dental, and vision exams
Healthy lifestyle choices: blood pressure, cholesterol, body mass index,
smoking cessation
Engagement Snapshot
Achieve 2,600 points to qualify for the 15 percent wellness discount:
December 2015
Complete the health survey: January 2016
Call a health coach: starting in February 2016
Earn additional wellness points throughout the year toward
the 2,600 point goal and qualify for the 2017 discount
3
Blue Cross Blue Shield of Illinois Blue Cross Blue Shield of Illinois
Buy-Up Plan Basic Plan
1/1/2016 1/1/2016
Greenville PPO Out-of-Network Greenville PPO Out-of-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
Keep up with your annual physical, dental, and vision exams
Healthy lifestyle choices: blood pressure, cholesterol, body mass index,
smoking cessation
Engagement Snapshot
Achieve 2,600 points to qualify for the 15 percent wellness discount:
December 2015
Complete the health survey: January 2016
Call a health coach: starting in February 2016
Earn additional wellness points throughout the year toward
the 2,600 point goal and qualify for the 2017 discount
3
