Page 34 - 2021-2022 New Hire Benefits

FlexPOS Copayment Prescription Drug Plan for

Use with Health Savings Account (HSA) 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 member pays the Generic drug cost-share plus the di erence in price between
the generic equivalent and the brand name drug.
Your Plan includes the following: Mandatory drug substitution, Generic substitution program, Tiered cost-
share program, and Voluntary mail order program.

In-network member pays Out-of-network member pays
Your deductible
Deductible is combined for $2,000 Individual $2,500 Individual
medical services and prescription $4,000 Family $5,000 Family
drugs
Your out-of-pocket maximum
Includes a combination of $3,000 Individual $4,500 Individual
deductible, copayments and $6,000 Family $9,000 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 after plan
(Tier 1) after plan deductible deductible

Preferred brand drugs $30 copayment/prescription 50% coinsurance after plan
(Tier 2) after plan deductible deductible

Non-preferred brand drugs $40 copayment/prescription 50% coinsurance after plan
(Tier 3) after plan deductible deductible
Mail Order Pharmacy
(up to a 90 day supply per In-network member pays Out-of-network member pays
prescription)

Generic drugs $10 copayment/prescription 50% coinsurance after plan
(Tier 1) after plan deductible deductible

CICI Flex and Combined/BS LG (01/2021) E ective Date: 7/2021
FlexPOS-CNT-HS129631
CT P01654141/P01654142 / MA P01754144/P01754143 -129631
FlexPOS-CNT-HSA-2000I/4000F-30-45-08
Bene t ID: LS/LT