Page 22 - 2021-2022 New Hire Benefits
P. 22

Prescription Drug Copayment with Deductible

       Plan Bene t Summary


       This is a brief summary of your prescription drug bene ts. Refer to your prescription drug rider for complete
       details on bene ts, conditions, limitations and exclusions, or consult with your bene ts manager.  All bene ts
       described below are per member per Contract year.

       Personalized for: CISHP






        Covered prescription drugs through retail participating pharmacies or our mail order service. Generics are
        dispensed unless the provider writes "Dispense as Written" on the prescription.

        Your Plan includes the following: Mandatory drug substitution, Generic substitution program, Pay the
        di erence waiver, Tiered cost-share program, and Voluntary mail order program.


                                              In-network member pays              Out-of-network member pays

                                              $100 Individual
                                              $200 Family
        Your deductible                                                           None
                                              Tier 1 drugs are exempt from this
                                              bene t deductible

        Your out-of-pocket maximum
        Includes a combination of             $4,000 Individual                   $4,000 Individual
        deductible, copayments and            $8,000 Family                       $8,000 Family
        coinsurance for medical and
        pharmacy services

        Retail Pharmacy
        (up to a 30 day supply per            In-network member pays              Out-of-network member pays
        prescription)
        Generic drugs                         $5 copayment/prescription           50% coinsurance
        (Tier 1)
        Preferred brand drugs                 $35 copayment/prescription          50% coinsurance
        (Tier 2)                              after bene t deductible

        Non-preferred brand drugs             $40 copayment/prescription          50% coinsurance
        (Tier 3)                              after bene t deductible

        Mail Order Pharmacy
        (up to a 90 day supply per            In-network member pays              Out-of-network member pays
        prescription)
        Generic drugs
        (Tier 1)                              $10 copayment/prescription          50% coinsurance






       CICI FlexPOS and Combined/BS LG (01/2021) E ective Date: 7/2021
       FlexPOS-CNT-30129705
       CT P01656449 / MA P01756450 -129705
       FlexPOS-CNT-30-45-300-500D-01
       Bene t ID: Lo
   17   18   19   20   21   22   23   24   25   26   27