Page 59 - 2022 Large Group benefits

51+
Prescription Drug12 14
Benefits per contract year
Value Rx $3/$20/$40/$60/50% up to $500
You pay in-network
Value Rx $3/$15/$35/$50/50% up to $500
You pay in-network
Value Rx $3/$10/$20/$35/50% up to $500
You pay in-network
$3 $3 $3 $20 $15 $10 $40 $35 $20 $60 50% up to $500
max
$50 $35 50% up to $500
max
50% up to $500
max
Low-cost generic13 15 16 Generic drugs13 16 Preferred brand13 16 Non-preferred drugs13 16 Self-administered specialty17
100+
Low-cost generic13 15 16 Generic drugs13 16 Preferred brand13 16 Non-preferred drugs13 16 Self-administered specialty17
$3 $20 $40 $60 50% up to $500
max
$3 $15 $35 $50 50% up to $500
max
Prescription Drug12 14
Benefits per contract year
Value Rx $3/$20/$75/ $100/50% up to $1 $1 000
You pay in- network
Value Rx $3/$20/$40/ $70/50% up to $1 000
You pay in- network
Value Rx $250/$3/10% no ded 20%/30%/50% up to $500
You pay in-network
Value Rx $3/$20/$40/ $60/50% up to $500
You pay in-network
Value Rx $3/$15/$35/ $50/50% up to $500
You pay in-network
$3 $20 $3 $3 — no deductible
$20 10% coinsurance — no ded $75 $40 20% after ded†
$100 $70 30% after ded†
50% up to $1 000
max
50% up to $1 000
max
50% up to $500
max
after ded†
Prescription Drug12 14
Benefits per contract year
Value Rx $3/$10/$40/ $70/50% up to $500
You pay in- network
Value Rx $3/20%/20%/ 20%/50% up to $500
You pay in- network
Value Rx $3/$10/$30/ $50/50% up to $500
You pay in-network
Value Rx $3/$10/$25/ $50/50% up to $500
You pay in-network
Value Rx $3/$10/$20/ $35/50% up to $500
You pay in-network
$3 $3 $3 $10 20% $10 $40 20% $70 $30 20% $50 50% up to $500
max
50% up to $500
max
50% up to $500
max
Low-cost generic13 15 16 Generic drugs13 16 Preferred brand13 16 Non-preferred drugs13 16 Self-administered specialty17
$3 $10 $25 $50 50% up to $500
max
$3 $10 $20 $35 50% up to $500
max
2022 Large Group Plans | Independence Blue Cross 58