Page 49 - 2023-large-group-marketing-brochure

51+
Prescription Drug12,14
Value Rx $3/$20/$40/$60/50% up to $500
Value Rx $3/$15/$35/$50/50% up to $500
Value Rx $3/$25/$50/$75/50% up to $500
Benefits per contract year
You pay in-network
You pay in-network
You pay in-network
$3
$3
$3
$20
$15
$25
$40
$35
$50
$60
$50
$75
50% up to $500 max
50% up to $500 max
50% up to $500 max
Low-cost generic drugs13,15,16 Generic drugs13,16
Preferred brand drugs13,16 Non-preferred drugs13,16 Self-administered specialty drugs17
100+
Low-cost
generic drugs13,15,16
Generic drugs13,16
Preferred brand drugs13,16 Non-preferred drugs13,16
Self-administered specialty drugs17
Prescription Drug12,14
Value Rx $3/$20/$75/ $100/50% up to $1,000
Value Rx $3/$20/$40/ $70/50% up to $1,000
Value Rx $250/$3/10% no ded 20%/30%/50% up to $500
Value Rx $3/$20/$40/ $60/50% up to $500
Value Rx $3/$15/$35/ $50/50% up to $500
Benefits per contract year
You pay in-network
You pay in-network
You pay in-network
You pay in-network
You pay in-network
$3
$3
$3 — no ded
$3
$3
$20
$20
10% coinsurance — no ded
$20
$15
$75
$40
20% after ded18
$40
$35
$100
$70
30% after ded18
$60
$50
50% up to $1,000 max
50% up to $1,000 max
50% up to $500 max after ded18
50% up to $500 max
50% up to $500 max
Prescription Drug12,14
Benefits per contract year
Value Rx $3/$10/$40/ $70/50% up to $500
Value Rx $3/20%/20%/ 20%/50% up to $500
Value Rx $3/$10/$30/ $50/50% up to $500
Value Rx $3/$10/$25/ $50/50% up to $500
Value Rx $3/$10/$20/ $35/50% up to $500
You pay in-network
You pay in-network
You pay in-network
You pay in-network
You pay in-network
$3
$3
$3
$3
$3
$10
$70
20%
20%
$10
$50
$10
$10
$40
20%
$30
$25
$50
$20
$35
50% up to $500 max
50% up to $500 max
50% up to $500 max
50% up to $500 max
50% up to $500 max
Low-cost
generic drugs13,15,16
Generic drugs13,16
Preferred brand drugs13,16
Non-preferred drugs13,16
Self-administered specialty drugs17
Footnotes begin on page 58 | ded = Deductible
2023 Large Group Plans | Independence Blue Cross 48