Page 17 - 2015 Advia CU Open Enrollment PPT
P. 17
BCN HMO HSA PLAN
$ 4 Copay (Tier IA - Value)
$ 15 Copay (Tier IB – Generics)
$ 40 Copay (Tier II – Preferred Brand)
$ 80 Copay (Tier III – Non-Preferred Drugs)
20% Co-insurance (Preferred Specialty)
$200 maximum
20% Co-insurance (Non-Preferred Specialty)
$300 maximum
$ 4 Copay (Tier IA - Value)
$ 15 Copay (Tier IB – Generics)
$ 40 Copay (Tier II – Preferred Brand)
$ 80 Copay (Tier III – Non-Preferred Drugs)
20% Co-insurance (Preferred Specialty)
$200 maximum
20% Co-insurance (Non-Preferred Specialty)
$300 maximum
