Prescription Drug Coverage

Prescription drug coverage is the same across all three medical plans, so you’ll have the same prescription benefits no matter which plan you choose.

Plan Features	EPO Plan	PPO Plan		HDHP + HSA Plan
	In-Network Only	In-Network	Out-of-Network	In-Network	Out-of-Network
Annual Deductible Individual/Family	N/A	N/A	N/A	$4,000** / $8,000**	$8,000** / $16,000**
Annual Out-of-Pocket Maximum Individual/Family	$2,000/person*	$2,000/person*	$2,000/person*	$8,000** / $16,000**	$16,000** / $32,000**
Prescription Drugs: Retail (up to a 30-day supply)
Maintenance Drugs (Generic)	$5	$5	$20	$5	$20
Generic	$10	$10	$20	$10 after deductible	$20 after deductible
Preferred Brand	$20	$20	$40	$20 after deductible	$40 after deductible
Non-Preferred Brand	$40	$40	$80	$40 after deductible	$80 after deductible
Specialty	$0***	$0***	$0***	$0***	$0***
Prescription Drugs: Mail Order (up to a 90-day supply)
Maintenance Drugs (Generic)	$10	$10	N/A	$10 after deductible	N/A
Generic	$20	$20	N/A	$20 after deductible	N/A
Preferred Brand	$40	$40	N/A	$40 after deductible	N/A
Non-Preferred Brand	$80	$80	N/A	$80 after deductible	N/A

*Separate from medical plan out-of-pocket maximum.

**Combined with medical deductible and out-of-pocket maximum.

***No cost if enrolled in PrudentRx, 30% coinsurance if not enrolled in PrudentRx.

Specialty Medications

By enrolling in PrudentRx, you will pay $0 for your specialty medication, if included in the specialty medication list. If you do not enroll, you’ll pay 30% of the medication cost.

Note: Pre-certification is required, and prescriptions must be filled through CVS Specialty Pharmacy.

Save More!

Download your RxSavingsPlus discount card at: rxsavingsplus.com/9712A081401.