|
A Monthly
Premium |
$20.04 |
$28.56 |
$35.29 |
|
Annual Deductible |
$250 |
$0 |
$0 |
|
A flat-dollar amount (copay-
ment) or a percentage of
the
cost (coinsurance) for covered
generic, brand or other prescription drugs,
until the annual cost of prescription
drugexpenses reaches $2250. (This
includes any deductible,
copay-ments or coinsurance.)
|
30-day supply*
Generic: $5
Brand: $25
Injectable drugs: 25%
|
30-day supply*
Generic: $10
Brand: $30
Injectable drugs: 30%
|
30-day supply*
Generic: $10
Brand: $30
Non-Preferred Brand: $60
Injectable drugs: 30%
|
|
90-day supply* Preferred
Mail Order Pharmacy:
Generic: $7.50
Brand: $62.50
Injectable drugs: 25%
Retail 90-day Pharmacy:
Generic: $15
Brand: $75
Injectable drugs: 25% |
90-day supply* Preferred
Mail Order Pharmacy:
Generic: $15
Brand: $75
Injectable drugs: 25%
Retail 90-day Pharmacy:
Generic: $30
Brand: $90
Injectable drugs: 30% |
90-day supply* Preferred
Mail Order Pharmacy:
Generic: $15
Brand: $75
Non-Preferred Brand: $150
Injectable drugs: 25%
Retail 90-day Pharmacy:
Generic: $30
Brand: $90
Non-Preferred Brand: $180
Injectable drugs: 30% |
|
View
Brochure Click Here
See page 4 for explanation
of Coverage Gap.
The cost for covered prescription
drug expenses
between $2250 in drug costs
and $3600 in annual
out-of-pocket costs.
|
100%
of the cost
|
100%
of the cost
|
30-day supply* Generic:
$10
90-day supply* Preferred
Mail Order
Pharmacy: Generic: $15
Retail 90-day Pharmacy:
Generic: $30 |
|
The cost for covered
prescription drugs after
you have paid $3600 in
annual out-of-pocket costs.
You pay a flat-dollar amount
or 5%, whichever is greater. |
Generic/Preferred
Multisource Brand:
$2 or 5%
whichever is greater
All others: $5 or 5% whichever
is greater |
Generic/Preferred
Multisource Brand:
$2 or 5%
whichever is greater
All others: $5 or 5% whichever
is greater |
Generic/Preferred
Multisource Brand:
$2 or 5%
whichever is greater
All others: $5 or 5% whichever
is greater |
