Page 4 - 2015 NVW Open Enrollment Guide

Open
Enrollment

Medical/

Prescription UnitedHealthcare UnitedHealthcare

Buy-Up Plan Basic Plan
1/1/2015 1/1/2015
Out-of-
Out-of-
POS Network POS Network
Prescription Drugs
Retail—31 Day Supply
Generic $10 Copay Copay + $10 Copay Copay +
Difference Difference
Formulary $35 Copay Copay + $35 Copay Copay +
Difference Difference
Non-Formulary $60 Copay Copay + $60 Copay Copay +
Difference Difference
Mail Order—90 Day Supply
Generic $25 Copay Not Covered $25 Copay Not Covered
Formulary $87 .50 Copay Not Covered $87 .50 Copay Not Covered
Non-Formulary $150 Copay Not Covered $150 Copay Not Covered
Mandatory Mail Order (Included for Maintenance Medications)

Bi-Weekly Contributions (26 Pay Periods)

Buy-Up Plan Basic Plan
Employee Only $105 .09 $76 .41
Employee + Spouse $286 .59 $229 .50
Employee + Child(ren) $241 .22 $191 .27
Employee + Family $422 .71 $344 .22

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