<p> 2017</p><p>Prescription Coverage</p><p>Prescription drug co-insurance & co-pays at your local retail pharmacy BCBS PPO High Deductible BCBS PPO Low Deductible Plan (30 day supply) HSA Plan</p><p>Generic 25% of total drug cost* $5 co-pay</p><p>Generic Preventative Drugs: Preventive generic drugs covered at $5 co-pay See the HSA Preventive Drug List $5 co-pay</p><p>25% of total drug cost. Formulary 25% of total drug cost* $30 minimum co-pay/ $80 maximum co-pay</p><p>40% of total drug cost. Non-formulary 25% of total drug cost* $60 minimum co-pay/ $150 maximum co-pay</p><p>Prescription drug co-insurance & co-pays at Mail Order BCBS PPO High Deductible BCBS PPO Low Deductible Plan or your local retail pharmacy (90 day supply) HSA Plan</p><p>Generic 25% of total drug cost* $10 co-pay</p><p>Generic Preventive Drugs: Preventive generic drugs covered at $10 co-pay See the HSA Preventive Drug List $10 co-pay</p><p>25% of total drug cost. Formulary 25% of total drug cost* $60 minimum/ $120 maximum co-pay 40% of total drug cost. Non-formulary 25% of total drug cost* $120 minimum /$200 maximum co-pay ACA Preventive Medication: Women’s Contraceptives (generics and select brands), Breast Cancer Prevention, Aspirin, Folic Acid/Prenatals, Fluoride 100% coverage 100% coverage (ages 6 mos. – 6 yrs.), Iron, Vitamin D (age 65 and older), Smoking Cessation Products, Immunizations, Colorectal Cancer Screening Prep Agents. Note: Not all prescription drugs are covered under these Plans, including the ACA Preventive Medication class. Additionally, Prior Authorization, Step Therapy, Quantity Limits, and Mandatory Specialty Pharmacy programs are in place and may be required in certain drug classes. Mandatory Maintenance program is required for all ongoing maintenance medications. Contact OptumRx for more details on the formulary drug list, costs and excluded drugs. </p><p>*Must meet deductible prior to the Plan paying co-insurance. If family coverage is elected, the entire family deductible must be met prior to co-insurance being paid.</p>