Prescription Plans. The following pages provides you with a side by side comparison of your benefit options to assist you in making your decision. It is intended as an easy-to-read summary and provides a general overview of your benefits. The below is not a contract, additional limitations and exclusions may apply. Payment amounts are based on BCBSM’s approved amount, less any applicable deductible and/or copay. PLEASE REFER TO YOUR BCBSM BENEFIT SUMMARY FOR ADDITIONAL INFORMATION INCLUDING OUT-OF-NETWORK BENEFITS. Community Blue PPO BCBS 100/80% with $150/$300 deductible Community Blue PPO BCBS 100/80% with $1,000/$2,000 deductible Simply Blue PPO HSA $1,400/$2,800 Plan In-Network In-Network In-Network Deductible per calendar year Individual $150 $1,000 $1,400 Family (two or more) $300 $2,000 $2,800* Copays Copays $10 copay for office visitsand office consultations $50 copay for emergencyroom visits $10 copay for office visitsand office consultations $50 copay for emergencyroom visits All services are subject to the deductible. See “Prescription Drugs” section for Rx copays Dollar Maximum (per HCR) Annual out-of-pocket $150 for one member, $300 for two or more members each calendar year $3,500 for one member $7,000 for two or more members each calendar year $2,250 for one person contract or $4,500 for two ormore members each calendar year maximums— applies to deductible, copays and coinsurance amounts for all covered services—including prescription drugcopays and coinsurance amounts, if applicable. *The full family deductible must be met under a two-person or family contract before benefits are paid for any person on the contract. Medical/Prescription Plans (Continued) Community Blue PPOBCBS 100/80% with $150/$300 deductible Community Blue PPOBCBS 100/80% with $1,000/$2,000 deductible Simply Blue PPO HSA $1,400/$2,800 Plan In-Network In-Network In-Network PREVENTIVE CARE (age and maximum number of services may apply) - please refer to the BCBSM website for additional information on these services as well as a listing of all of the covered preventive services. Health Maintenance Exam Covered 100% Covered 100% Covered 100% Annual Gynecological Exam Covered 100% Covered 100% Covered 100% Pap Smear Screening laboratory & pathology services Covered 100% Covered 100% Covered 100% Mammography Screening Covered 100% Covered 100% Covered 100% Well-baby and Child Care Covered 100% Covered 100% Covered 100% Immunizations Covered 100% Covered 100% Covered 100% PHYSICIAN OFFICE SERVICES ...
Prescription Plans. The County shall offer a prescription plan with a national network, included in the premium cost for all County medical plans. The following 3-tier formulary prescription plan will be includedwith the CIGNA OAP and OAPIN Medical plans Prescriptions filled at retail pharmacies Prescriptions filled through Mail Order -up to 34 daysupply pharmacy -up to 102 day supply $5 copay for Generic Drug $10 copay for Generic Drug $20 copay for Brand Formulary Drug $40 copay for Brand Formulary Drug $35 copay for Brand non-Formulary Drug $70 copay for Brand non-Formulary Drug The County shall provide for the participation of the Health Care Review Committee in the review of the prescription plan formulary Network and Care Management utilized by the prescription plan administrator and periodic review of the formulary. Prescription plans shall be included with the medical plans.
Prescription Plans. The County shall offer a prescription plan with a national network, included in the premium cost for all County medical plans. The following 3-tier formulary prescription plan will be included with the CIGNA OAP and OAPIN Medical plans Prescriptions filled at retail pharmacies – up to 34 day supply Prescriptions filled through Mail Order pharmacy – up to 102 day supply $5 copay for Generic Drug $10 copay for Generic Drug $20 copay for Brand Formulary Drug $40 copay for Brand Formulary Drug $35 copay for Brand non-Formulary Drug $70 copay for Brand non-Formulary Drug Effective January 1, 2015 Prescriptions filled at retail pharmacies – up to 34 day supply Prescriptions filled through Mail Order pharmacy – up to 102 day supply $12 copay for Generic $24 copay for Generic Drug $30 copay for Brand Formulary Drug $60 copay for Brand Formulary Drug $45 copay for Brand non-Formulary Drug $90 copay for Brand non-Formulary Drug Medicare Supplemental RX Deductible: Effective September 1, 2007 $75 person/year Effective September 1, 2008 $100 person/year The County shall provide for the participation of the Health Care Review Committee in the review of the prescription plan formulary Network and Care Management utilized by the prescription plan administrator and periodic review of the formulary. Prescription plans shall be included with the medical plans.
Prescription Plans. The County shall offer a prescription plan with a national network, included in the premium cost for all County medical plans. The following 3-tier formulary prescription plan will be included with the CIGNA OAP and OAPIN Medical plans Effective January 1, 2015 Prescriptions filled at retail pharmacies Prescriptions filled through Mail Order pharmacy-up to 34 day supply -up to 102 day supply $12 copay for Generic $24 copay for Generic Drug $30 copay for Brand Formulary Drug $60 copay for Brand Formulary Drug $45 copay for Brand non-Formulary Drug $90 copay for Brand non-Formulary Drug Medicare Supplemental RX Deductible: Effective September 1, 2007 $75 person/year Effective September 1, 2008 $100person/year The County shall provide for the participation of the Health Care Review Committee in the review of the prescription plan formulary Network and Care Management utilized by the prescription plan administrator and periodic review of the formulary. Prescription plans shall be included with the medical plans.
Prescription Plans. Xxxxxxxxx will reimburse National for prescription claims paid by National.
Prescription Plans. The County shall offer a prescription plan with a national network, included in the premium cost for all County medical plans. The following 3-tier formulary prescription plan will be included with the Triple Option medical plan: Prescriptions filled at retail pharmacies – Prescriptions filled through Mail Order pharmacy – up to 34-day supply up to 100-day supply - $5 co-pay for Generic Drug - $10 co-pay for Generic Drug - $20 co-pay for Brand Formulary Drug - $40 co-pay for Brand Formulary Drug - $35 co-pay for Brand non-Formulary Drug - $70 co-pay for Brand non-Formulary Drug Medicare RX Deductible:
