Prescription Drug

Retail:
20% ($10 min/$40 max);
no deductible

Mail Order:20% ($25 min/$100 max);

Retail:30% ($40 min/$75 max);
no deductible

Mail Order:30% ($100 min/$185 max);

Retail40% ($55 min/$125 max);
no deductible

Mail Order:40% ($140 min/$315 max);

Retail:If not covered by PrudenRx:
$150; no deductible iCertain specialty medications may be eligible for additional benefits through the PrudentRx Copay Program so your cost-sharing is reduced to $0. See the list of specialty medications covered under the Copay Program (https://www.prudentrx.com/prudentes). If you opt out of the Prudent Rx Copay Program, you will pay 30% coinsurance for specialty medications that are covered by the PrudentRx Copay Program. If your specialty medication is not covered by the PrudentRx Copay Program, then you will be responsible for the $150 copay listed in this chart. The Plan and the PrudentRx Copay Program categorize specialty medications as either “essential health benefits” or “non-essential health benefits.” Employee cost-sharing for “essential health benefits” counts toward the Plan out-of-pocket maximum but does not count toward the Plan deductible. On the other hand, employee cost-sharing for “non-essential health benefits” does not count toward either the Plan deductible or out-of-pocket maximum. Also, even if you reach your out-of-pocket maximum, you will still be responsible for your cost-sharing amount for specialty medications that are “non-essential health benefits.” Specialty medications that have been deemed “non-essential health benefits” are denoted with a “1” on the list at the hyperlink above. If you have any questions, contact PrudentRx at 1-800-578-4403.If covered by PrudentRX:
30%; no deductible iCertain specialty medications may be eligible for additional benefits through the PrudentRx Copay Program so your cost-sharing is reduced to $0. See the list of specialty medications covered under the Copay Program (https://www.prudentrx.com/prudentes). If you opt out of the Prudent Rx Copay Program, you will pay 30% coinsurance for specialty medications that are covered by the PrudentRx Copay Program. If your specialty medication is not covered by the PrudentRx Copay Program, then you will be responsible for the $150 copay listed in this chart. The Plan and the PrudentRx Copay Program categorize specialty medications as either “essential health benefits” or “non-essential health benefits.” Employee cost-sharing for “essential health benefits” counts toward the Plan out-of-pocket maximum but does not count toward the Plan deductible. On the other hand, employee cost-sharing for “non-essential health benefits” does not count toward either the Plan deductible or out-of-pocket maximum. Also, even if you reach your out-of-pocket maximum, you will still be responsible for your cost-sharing amount for specialty medications that are “non-essential health benefits.” Specialty medications that have been deemed “non-essential health benefits” are denoted with a “1” on the list at the hyperlink above. If you have any questions, contact PrudentRx at 1-800-578-4403.

Mail Order:More than 30-day supply not allowed

Retail:If not covered by PrudenRx:
$210; no deductible iCertain specialty medications may be eligible for additional benefits through the PrudentRx Copay Program so your cost-sharing is reduced to $0. See the list of specialty medications covered under the Copay Program (https://www.prudentrx.com/prudentes). If you opt out of the Prudent Rx Copay Program, you will pay 30% coinsurance for specialty medications that are covered by the PrudentRx Copay Program. If your specialty medication is not covered by the PrudentRx Copay Program, then you will be responsible for the $210 copay listed in this chart. The Plan and the PrudentRx Copay Program categorize specialty medications as either “essential health benefits” or “non-essential health benefits.” Employee cost-sharing for “essential health benefits” counts toward the Plan out-of-pocket maximum but does not count toward the Plan deductible. On the other hand, employee cost-sharing for “non-essential health benefits” does not count toward either the Plan deductible or out-of-pocket maximum. Also, even if you reach your out-of-pocket maximum, you will still be responsible for your cost-sharing amount for specialty medications that are “non-essential health benefits.” Specialty medications that have been deemed “non-essential health benefits” are denoted with a “1” on the list at the hyperlink above. If you have any questions, contact PrudentRx at 1-800-578-4403.If covered by PrudentRX:
30%; no deductible iCertain specialty medications may be eligible for additional benefits through the PrudentRx Copay Program so your cost-sharing is reduced to $0. See the list of specialty medications covered under the Copay Program (https://www.prudentrx.com/prudentes). If you opt out of the Prudent Rx Copay Program, you will pay 30% coinsurance for specialty medications that are covered by the PrudentRx Copay Program. If your specialty medication is not covered by the PrudentRx Copay Program, then you will be responsible for the $210 copay listed in this chart. The Plan and the PrudentRx Copay Program categorize specialty medications as either “essential health benefits” or “non-essential health benefits.” Employee cost-sharing for “essential health benefits” counts toward the Plan out-of-pocket maximum but does not count toward the Plan deductible. On the other hand, employee cost-sharing for “non-essential health benefits” does not count toward either the Plan deductible or out-of-pocket maximum. Also, even if you reach your out-of-pocket maximum, you will still be responsible for your cost-sharing amount for specialty medications that are “non-essential health benefits.” Specialty medications that have been deemed “non-essential health benefits” are denoted with a “1” on the list at the hyperlink above. If you have any questions, contact PrudentRx at 1-800-578-4403.

Mail Order:More than 30-day supply not allowed