Page 14 - 2015 Advia CU Benefits & Notices
P. 14
Advia CU - MI 2015
Prescription Drugs (Tier IA) Value Generics – $6 copay;
Pharmacy (30 day supply) (Tier IB) Generics – $40 co-pay;
Pharmacy/Mail Order (90-day supply) (Tier II) Formulary Brand - $60 co-pay;
(Tier III) Non-Formulary Brand - $80 co-pay;
(Tier IV) Formulary Specialty Drugs – 20% co-insurance up to $200;
(Tier V) Non-Formulary Specialty Drugs – 20% co-insurance up to $300
Sexual Dysfunction Drugs – 50% coinsurance
3x regular retail co-pay LESS $10 (Does not include Tier IV & V Drugs)
Salus Group© Copyright 2014 Page | 14
Prescription Drugs (Tier IA) Value Generics – $6 copay;
Pharmacy (30 day supply) (Tier IB) Generics – $40 co-pay;
Pharmacy/Mail Order (90-day supply) (Tier II) Formulary Brand - $60 co-pay;
(Tier III) Non-Formulary Brand - $80 co-pay;
(Tier IV) Formulary Specialty Drugs – 20% co-insurance up to $200;
(Tier V) Non-Formulary Specialty Drugs – 20% co-insurance up to $300
Sexual Dysfunction Drugs – 50% coinsurance
3x regular retail co-pay LESS $10 (Does not include Tier IV & V Drugs)
Salus Group© Copyright 2014 Page | 14
