Plan Year 7/1/11 - 6/30/12 Plan Facts Cost

Annual Rx out-of-pocket maximumRetail genericRetail formulary brandRetail nonformulary brandMail order genericMail order formulary brandMail order nonformulary brandOral contraceptivesFertility drugsNot applicableIn NetworkNot applicableOut of NetworkNot applicableIn Network$7 copay; 30 day supply; participating pharmaciesonlyOut of Network80% covered; after $7 copay; 30 day supplyIn Network$30 copay; 30 day supply; participating pharmaciesonlyOut of Network80% covered; after $30 copay; 30 day supplyIn Network$30 copay; plus $35 cost-sharing charge for nonformularydrug; participating pharmacies only; 30 daysupplyOut of Network80% covered; after $30 copay and $35 cost-sharingcharge for non-formulary drug$11 copay; 90 day supply$65 copay; 90 day supply$170 copay; 90 day supplyIn NetworkRetail and mail order available; applicable prescriptiondrug formulary and copays apply; check with Plan fordetailsOut of NetworkRetail available only; applicable prescription drugformulary and copays apply; check with Plan fordetailsIn NetworkCheck with Plan for detailsOut of NetworkCheck with Plan for detailsCoverageHMSA PPOAnnual physical examWell-woman exam (includes pap)In NetworkNot covered; health assessment available only throughthe HealthPass program; HealthPass screenings 100%covered; check with Plan for detailsOut of NetworkNot coveredIn Network100% coveredOut of Network