Page 12 - PriMed 2022 Benefits Guide

Prescription Drug Coverage

PLEASE NOTE: The PPO Plan is available to employees who work outside of California but within the 48
contiguous United States, who do not have access to an HMO coverage area within California, or who do not have
access to Hill Physicians Medical Group. The HMO plans are available employees – Networks vary between plans.

Your medical plans include prescription drug coverage through Blue Shield. Remember to use participating
pharmacies to save the most money. You can access a list of pharmacies through your plan’s website or by
calling member services.

Health Net HMO Health Net HMO Health Net Health Net PPO
Plan Features
with CanopyCare with SmartCare Full Network HMO (250-10-OV-90/70)
In-Network Only In-Network Only In-Network Only In-Network Out-of-Network

DRUG DEDUCTIBLE: $250 per calendar year (applicable to Brand Tier for all plans)
Prescription Drugs: Retail (up to a 30-day supply)
Tier 1 $15 copay $15 copay $15 copay $15 copay $15 copay +25%
Generic
Tier 2 $30 copay $30 copay $30 copay $30 copay $30 copay +25%
Brand & Preferred
1
Tier 3 $45 copay $45 copay $45 copay $45 copay
Non-Formulary $45 copay +25%
Tier 4 20% up to 20% up to 20% up to 30% up to Not Covered
Specialty Tier $200/script $200/script $200/script $200/script

Mail Order (90-day supply)
Tier 1 $30 copay $30 copay $30 copay $30 copay Not Covered

Tier 2 $60 copay $60 copay $60 copay $60 copay
Tier 3 $90 copay $90 copay $90 copay $90 copay
Tier 4 N/A N/A N/A N/A
1 Benefits are paid after the deductible is met

This chart provides a brief overview of benefits and coverage. Refer to the detailed summary plan documents for
questions about a specific procedure, service, or provider. In the event of a conflict, the official plan documents
prevail.

PRIME Program
PriMed’s Clinical Support Department is available to meet with you privately to discuss your
prescriptions, via our PRIME program. They can help you evaluate and identify ways to save
money on your own prescription costs. If you are interested in this type of savings, then you
may contact clinicalsupport@hpmg.com to ask a question or schedule a one-on-one meeting.
Please note that pharmacists may reply within 24-48 hours based on availability.

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