Prescription Rx Plan
| | Anthem 2000 PPO |
Anthem 5000 PPO |
Anthem HSA 6500 PPO |
|||
|---|---|---|---|---|---|---|
| Member Responsibility | In-Network | In-Network | In-Network | |||
| Retail Pharmacy (30-day supply) | ||||||
| Pharmacy Deductible | $0 Ind./$0 Family | $500 Ind./$1,000 Family | Medical Ded of $6500 Applies | |||
| Generic (Tier 1)* | $5 | $5 AD | $15 AD | |||
| Preferred (Tier 2) | $50 | $50 AD | $50 AD | |||
| Non-Preferred (Tier 3) | $100 | $100 AD | $85 AD | |||
| Preferred Specialty (Tier 4) | 20% up to $250 | 20% up to $250 AD | 20% up to $300 AD | |||
| Mail Order Pharmacy (90-day supply) | ||||||
| Generic (Tier 1) | $13 | $13 AD | $38 AD | |||
| Preferred (Tier 2) | $125 | $125 AD | $125 AD | |||
| Non-Preferred (Tier 3) | $250 | $250 AD | $213 AD | |||
| Preferred Specialty (Tier 4)** | 20% up to $250 | 20% up to $250 AD | 20% up to $300 AD | |||
| AD = After Deductible | ||||||
| * Deductible is waived for some preventive generics | ||||||
| ** 30 day supply only | ||||||
| Note: Out-of-network benefits available for all plans consist of higher premiums and coinsurance and may be susceptible to balance billing for any charges over the allowable limit for a service. Remaining in-network for services is advised. See SPD for details or anthem.com to see if your provider is in-network. | ||||||