Page 16 - 2015 Advia CU Benefits & Notices
P. 16
Prescription Drugs Advia CU - MI 2015
Pharmacy (30 day supply)
(Tier IA) Value Generics – $4 copay after deductible;
Pharmacy/Mail Order (90-day supply) (Tier IB) Generics – $15 co-pay after deductible;

(Tier II) Formulary Brand - $40 co-pay after deductible;
(Tier III) Non-Formulary Brand - $80 co-pay after deductible;
(Tier IV) Formulary Specialty Drugs – 20% after deductible;
(Tier V) Non-Formulary Specialty Drugs – 20% after deductible

Sexual Dysfunction Drugs – 50% coinsurance after deductible

3x regular retail co-pay LESS $10 after deductible
(Does not include Tier IV & V Drugs)

Salus Group© Copyright 2014 Page | 16
   11   12   13   14   15   16   17   18   19   20   21