Page 12 - 2016 Open Enrollment
P. 12
Open
Enrollment
Pharmacy Plan Highlights
Standard Plan Enhanced Plan Premium Plan HSA Plan ****
Out-of-
Out-of-
Out-of-
Out-of-
Plan Feature* In-Network Network In-Network Network In-Network Network In-Network Network
Prescripion Drug Program
Retail Pharmacy ***
Generic $10 copay $10 copay $10 copay Ded. and
Coin.
Brand Name *** See *** See *** See Ded. and *** See
Formula $30 copay below $30 copay below $30 copay below Coin. below
Brand name Ded. and
Non-Formulary $50 copay $50 copay $50 copay Coin.
Mail Order ***
Generic $20 copay $20 copay $20 copay Ded. and
Coin.
Brand Name Ded. and
Formula $60 copay Not covered $60 copay Not covered $60 copay Not covered Coin. Not covered
Brand name Ded. and
Non-Formulary $100 copay $100 copay $100 copay Coin.
* In-network beneits relect the negoiated fees charged by network providers. Out-of-network beneits are subject to R&C (reasonable and customary) limits.
** Copays and coinsurance under the in-network porion of a medical opion and the prescripion drug program will apply towards the medical out-of-pocket
maximum as required by healthcare reform legislaion.
*** For retail out of network pharmacy expenses you will be responsible for the diference between the Predominant Reimbursement Rate and a Network
Pharmacy’s Usual and Customary Charge (which includes a dispensing fee and sales tax) for that Prescripion Drug Product. Mail order out of network pharmacy
expenses are not covered.
**** The HSA PPO features a non-embedded deducible and out-of-pocket maximum; if you cover one or more dependents the full family deducible must be
saisied by one or more family members before cost sharing (coinsurance) begins and the full family out-of-pocket maximum must be saisied by one or
more family members before the plan begins covering 100% of eligible expenses during the plan year.
12
Enrollment
Pharmacy Plan Highlights
Standard Plan Enhanced Plan Premium Plan HSA Plan ****
Out-of-
Out-of-
Out-of-
Out-of-
Plan Feature* In-Network Network In-Network Network In-Network Network In-Network Network
Prescripion Drug Program
Retail Pharmacy ***
Generic $10 copay $10 copay $10 copay Ded. and
Coin.
Brand Name *** See *** See *** See Ded. and *** See
Formula $30 copay below $30 copay below $30 copay below Coin. below
Brand name Ded. and
Non-Formulary $50 copay $50 copay $50 copay Coin.
Mail Order ***
Generic $20 copay $20 copay $20 copay Ded. and
Coin.
Brand Name Ded. and
Formula $60 copay Not covered $60 copay Not covered $60 copay Not covered Coin. Not covered
Brand name Ded. and
Non-Formulary $100 copay $100 copay $100 copay Coin.
* In-network beneits relect the negoiated fees charged by network providers. Out-of-network beneits are subject to R&C (reasonable and customary) limits.
** Copays and coinsurance under the in-network porion of a medical opion and the prescripion drug program will apply towards the medical out-of-pocket
maximum as required by healthcare reform legislaion.
*** For retail out of network pharmacy expenses you will be responsible for the diference between the Predominant Reimbursement Rate and a Network
Pharmacy’s Usual and Customary Charge (which includes a dispensing fee and sales tax) for that Prescripion Drug Product. Mail order out of network pharmacy
expenses are not covered.
**** The HSA PPO features a non-embedded deducible and out-of-pocket maximum; if you cover one or more dependents the full family deducible must be
saisied by one or more family members before cost sharing (coinsurance) begins and the full family out-of-pocket maximum must be saisied by one or
more family members before the plan begins covering 100% of eligible expenses during the plan year.
12
