Prescription Drugs

Prescription Drugs:**
	HSA Plus		HSA Basic		PPO*
	In-Network	Out-of-Network	In-Network	Out-of-Network	In-Network	Out-of-Network
Retail (0–30 days)
Preventive	100% generic only (If no generic is available, the brand-name preventive prescription drug will be paid at 100%.)		100% generic only (If no generic is available, the brand-name preventive prescription drug will be paid at 100%.)		Covered the same as any other prescription drug
Tier 1	90% after deductible		80% after deductible		$15 copay
Tier 2					70% ($30 min/$100 max)
Tier 3					50% ($50 min/$200 max)
Mail (31–60 days)
Preventive	100% generic only (If no generic is available, the brand-name preventive prescription drug will be paid at 100%.)		100% generic only (If no generic is available, the brand-name preventive prescription drug will be paid at 100%.)		Covered the same as any other prescription drug
Tier 1	90% after deductible		80% after deductible		$15 copay
Tier 2					70% ($60 min/$200 max)
Tier 3					50% ($100 min/$400 max)
Mail (61–90 days)
Preventive	100% generic only (If no generic is available, the brand-name preventive prescription drug will be paid at 100%.)		100% generic only (If no generic is available, the brand-name preventive prescription drug will be paid at 100%.)		Covered the same as any other prescription drug
Tier 1	90% after deductible		80% after deductible		$30 copay
Tier 2					70% ($60 min/$250 max)
Tier 3					50% ($100 min/$400 max)
PPO only: Prescription drug costs apply to out-of-pocket maximum, not deductible. *All prescription drugs must be FDA approved to be covered. If a generic drug is available and you elect to purchase the brand-name drug instead, you will pay the difference between the generic and brand-name drug cost. If your doctor prescribes a brand-name drug, or if no generic is available, brand-name prescription drug will be paid per the plan. For some conditions, you may be required to try an equivalent but lower-cost drug first.