Page 13 - 2015 Advia CU Open Enrollment PPT
P. 13
CB PPO 250 PLAN
$20 Copay (Tier I - Generic)
$60 Copay (Tier II - Brand Formulary)
Approved brand name drugs
50% Co-insurance (Tier III - Brand Non-Formulary)
Higher priced brand drugs when lower cost equivalent exists
$80 minimum - $100 maximum)
20% Co-insurance (Tier IV) – Preferred Specialty Drugs
$200 maximum
20% Co-insurance (Tier V) – Non-Preferred Specialty Drugs)
$300 maximum
$20 Copay (Tier I - Generic)
$60 Copay (Tier II - Brand Formulary)
Approved brand name drugs
50% Co-insurance (Tier III - Brand Non-Formulary)
Higher priced brand drugs when lower cost equivalent exists
$80 minimum - $100 maximum)
20% Co-insurance (Tier IV) – Preferred Specialty Drugs
$200 maximum
20% Co-insurance (Tier V) – Non-Preferred Specialty Drugs)
$300 maximum
