Pharmacy Benefit Schedule

  BENEFIT EFFECTIVE
January 1, 2017
BENEFIT TYPE
Health Insurance Marketplace
GROUP TIER 1 GENERIC AND LOWER COST BRAND PRODUCTS TIER 2 PREFERRED BRAND AND HIGHER COST GENERICS TIER 3 NON PREFERRED BRAND (COULD INCLUDE BOTH BRAND AND GENERIC PRODUCTS) TIER 1 GENERIC AND LOWER COST BRAND PRODUCTS TIER 2 PREFERRED BRAND AND HIGHER COST GENERICS TIER 3 NON PREFERRED BRAND (COULD INCLUDE BOTH BRAND AND GENERIC PRODUCTS)
BENEFIT STRUCTURE  
  Retail In-Network Pharmacy 1-30 Days' Supply Retail In-Network Pharmacy 90 Days' Supply
HMO Bronze 003 Off Exchange $10 $85 $110 $30 $255 $330
HMO Bronze 003 $10 $85 $110 $30 $255 $330
HMO Bronze 003 Zero Cost Sharing Plan Variation $0 $0 $0 $0 $0 $0
HMO Bronze 003 Limited
Cost Sharing Plan Variation
$10 $85 $110 $30 $255 $330
  $0 when filled through an Indian Health Service Provider
HMO Silver 002 Off Exchange $35 $100 $110 $105 $300 $330
HMO Silver 002 $35 $100 $110 $105 $300 $330
HMO Silver 002 Zero
Cost Sharing Plan
Variation
$0 $0 $0 $0 $0 $0
HMO Silver 002 Limited
Cost Sharing Plan
Variation
$35 $100 $110 $105 $300 $330
  $0 when filled through an Indian Health Service Provider
HMO Silver 002 94 $5 $20 $40 $15 $60 $120
HMO Silver 002 87 $10 $35 $70 $30 $105 $210
HMO Silver 002 73 $25 $100 $110 $75 $300 $330
HMO Silver 004 Off Exchange $10 $50 $100 $30 $150 $300
HMO Silver 004 $10 $50 $100 $30 $150 $300
HMO Silver 004 Zero
Cost Sharing Plan
Variation
$0 $0 $0 $0 $0 $0
HMO Silver 004 Limite Cost Sharing Plan Variation $10 $50 $100 $30 $150 $300
  $0 when filled through an Indian Health Service Provider
HMO Silver 004 94 $5 $20 $40 $15 $60 $120
HMO Silver 004 87 $10 $35 $70 $30 $105 $210
HMO Silver 004 73 $10 $40 $90 $30 $120 $270
HMO Gold 001 Off
Exchange
$15 $40 $80 $45 $120 $240
HMO Gold 001 $15 $40 $80 $45 $120 $240
HMO Gold 001 Zero Cost
Sharing Plan Variation
$0 $0 $0 $0 $0 $0
HMO Gold 001 Limited
Cost Sharing Plan
Variation
$15 $40 $80 $45 $120 $240
  $0 when filled through an Indian Health Service Provider
HMO Gold 005 Off
Exchange
$10 $40 $70 $30 $120 $210
HMO Gold 005 $10 $40 $70 $30 $120 $210
HMO Gold 005 Zero Cost
Sharing Plan Variation
$0 $0 $0 $0 $0 $0
HMO Gold 005 Limited
Cost Sharing Plan
Variation
$10 $40 $70 $30 $120 $210
  $0 when filled through an Indian Health Service Provider
HMO Gold 006
KelseyCare Off Exchange
$15 $40 $80 $45 $120 $240
HMO Gold 006
KelseyCare
$15 $40 $80 $45 $120 $240
HMO Gold 006
KelseyCare Zero Cost
Sharing Plan Variationn
$0 $0 $0 $0 $0 $0
HMO Gold 006
KelseyCare Limited Cost
Sharing Plan Variation
$15 $40 $80 $45 $120 $240
  $0 when filled through an Indian Health Service Provider
HMO Silver 007 KelseyCare Off Exchange $35 $100 $110 $105 $300 $330
HMO Silver
007 KelseyCare
$35 $100 $110 $105 $300 $330
HMO Silver 007
KelseyCare Zero Cost
Sharing Plan Variation
$0 $0 $0 $0 $0 $0
HMO Silver 007
KelseyCare Limited Cost
Sharing Plan Variation
$35 $100 $110 $105 $300 $330
  $0 when filled through an Indian Health Service Provider
HMO Silver 007
KelseyCare 94
$5 $20 $40 $15 $60 $120
HMO Silver 007
KelseyCare 87
$10 $35 $70 $30 $105 $210
HMO Silver 007
KelseyCare 73
$25 $100 $110 $75 $300 $330

INDIVIDUAL ANNUAL PRESCRIPTION DEDUCTIBLE

Group
Individual Annual Prescription Deductible
HMO Bronze 003 Off Exchange $200
HMO Bronze 003 $200
HMO Bronze 003 Zero Cost Sharing Plan
Variation
$200
HMO Bronze 003 Limited Cost Sharing Plan
Variation
$200
The annual Out-of-Pocket (OOP) Maximum is based on combined prescription and medical expense and is calculated per calendar year. Member’s copay/coinsurance amount is $0.00 for remainder of calendar year after the OOP maximum amount is met for the calendar year.
Group
Individual OOP Amount
Family OOP Amount
HMO Bronze 003 Off Exchange $7,150 $14,300
HMO Bronze 003 $7,150 $14,300

HMO Bronze 003 Zero Cost Sharing Plan
Variation

$0 $0
HMO Bronze 003 Limited Cost Sharing Plan
Variation
$7,150 $14,300
HMO Silver 002 Off Exchange $7,150 $14,300
HMO Silver 002 $7,150 $14,300
HMO Silver 002 Zero Cost Sharing Plan
Variation
$0 $0
HMO Silver 002 Limited Cost Sharing Plan
Variation
$7,150 $14,300
HMO Silver 002 94 $1,000 $2,000
HMO Silver 002 87 $2,350 $4,700
HMO Silver 002 73 $5,700 $11,400
HMO Silver 004 Off Exchange $7,150 $14,300
HMO Silver 004 $7,150 $14,300
HMO Silver 004 Zero Cost Sharing Plan
Variation
$0 $0
HMO Silver 004 Limited Cost Sharing Plan
Variation
$7,150 $14,300
HMO Silver 004 94 $1,000 $2,000
HMO Silver 004 87 $2,350 $4,700
HMO Silver 004 73 $5,700 $11,400
HMO Gold 001 Off Exchange $5,000 $10,000
HMO Silver 004 73 $5,000 $10,000
HMO Gold 001 Zero Cost Sharing Plan Variation $0 $0
HMO Gold 001 Limited Cost Sharing Plan
Variation
$5,000 $10,000
HMO Gold 005 Off Exchange $5,000 $10,000
HMO Gold 005 $5,000 $10,000
HMO Gold 005 Zero Cost Sharing Plan
Variation
$0 $0
HMO Gold 005 Limited Cost Sharing Plan
Variation
$5,000 $10,000
HMO Gold 006 KelseyCare Off Exchange $5,000 $10,000
HMO Gold 006 KelseyCare $5,000 $10,000
HMO Gold 006 KelseyCare Zero Cost Sharing Plan
Variation
$0 $0
HMO Gold 006 KelseyCare Limited Cost Sharing Plan
Variation
$5,000 $10,000
HMO Silver 007 KelseyCare Off Exchange $7,150 $14,300
HMO Silver 007KelseyCare $7,150 $14,300
HMO Silver 007 KelseyCare Zero Cost Sharing
Plan Variation
$0 $0
HMO Silver 007 KelseyCare Limited Cost
Sharing Plan Variation
$7,150 $14,300
HMO Silver 007 KelseyCare 94 $1,000 $2,000
HMO Silver 007 KelseyCare 87 $2,350 $4,700
HMO Silver 007 KelseyCare 73 $5,700 $11,400

ADDITIONAL COVERAGE INFORMATION

   
Community Health Choice requires members to use generic medications when a generic is available. If a brand name drug is dispensed when a generic is available (multi-source brand), the member will pay the applicable copay plus the cost difference between the brand and generic, regardless if the doctor’s prescription indicates the branded medication should be dispensed. This amount will not apply to the member’s maximum out of pocket.
MAIL ORDER SERVICE
The Mail Order Service allows you to receive up to a 90-day supply of maintenance medications. This program is part of your pharmacy benefit and is voluntary
Mail Service In-Network Pharmacy 90 Days' Supply
  Copay Amount
GROUP TIER 1 GENERIC AND LOWER COST BRAND PRODUCTS TIER 2 PREFERRED BRAND AND HIGHER COST GENERICS TIER 3 NON PREFERRED BRAND (COULD INCLUDE BOTH BRAND AND GENERIC PRODUCTS)
HMO Bronze 003 Off Exchange $25 $212.50 $275
HMO Bronze 003 $25 $212.50 $275
HMO Bronze 003 Zero Cost Sharing Plan Variation $0 $0 $0
HMO Bronze 003 Limited
Cost Sharing Plan Variation
$25 $212.50 $275
  $0 when filled through an Indian Health Service Provider
HMO Silver 002 Off Exchange $87.50 $250 $275
HMO Silver 002 $87.50 $250 $275
HMO Silver 002 Zero
Cost Sharing Plan
Variation
$0 $0 $0
HMO Silver 002 Limited
Cost Sharing Plan
Variation
$87.50 $250 $275
  $0 when filled through an Indian Health Service Provider
HMO Silver 002 94 $12.50 $50 $150
HMO Silver 002 87 $25 $87.50 $175
HMO Silver 002 73 $62.50 $250 $275
HMO Silver 004 Off Exchange $25 $125 $250
HMO Silver 004 $25 $125 $250
HMO Silver 004 Zero
Cost Sharing Plan
Variation
$0 $0 $0
HMO Silver 004 Limited Cost Sharing Plan Variation $25 $125 $250
  $0 when filled through an Indian Health Service Provider
HMO Silver 004 94 $12.50 $50 $100
HMO Silver 004 87 $25 $87.50 $175
HMO Silver 004 73 $25 $100 $225
HMO Gold 001 Off
Exchange
$37.50 100 200
HMO Gold 001 37.50 $100 $200
HMO Gold 001 Zero Cost
Sharing Plan Variation
$0 $0 $0
HMO Gold 001 Limited
Cost Sharing Plan
Variation
$37.50 $100 $200
  $0 when filled through an Indian Health Service Provider
HMO Gold 005 Off Exchange $25 $100 $175
HMO Gold 005 $25 $100 $175
HMO Gold 005 Zero Cost Sharing Plan
Variation
$0 $0

$0

HMO Gold 005 Limited Cost Sharing Plan
Variation
$25 $100 $175
  $0 when filled through an Indian Health Service Provider
HMO Gold 006 KelseyCare Off Exchange $37.50 $100 $200
HMO Gold 006 KelseyCare $37.50 $100 $200
HMO Gold 006 KelseyCare Zero Cost
Sharing Plan Variation
$0 $0

$0

HMO Gold 006 KelseyCare Limited Cost
Sharing Plan Variation
$37.50 $100 $200
  $0 when filled through an Indian Health Service Provider
HMO Silver 007 KelseyCare Off Exchange $87.50 $250 $275
HMO Silver 007 KelseyCare $87.50 $250 $275
HMO Silver 007 KelseyCare Zero Cost
Sharing Plan Variation
$0 $0 $0
HMO Silver 007 KelseyCare Limited Cost
Sharing Plan Variation
$87.50 $250 $275
  $0 when filled through an Indian Health Service Provider
HMO Silver 007 KelseyCare 94 $12.50 $50 $100
HMO Silver 007 KelseyCare 87 $25 $87.50 $175
HMO Silver 007 KelseyCare 73 $62.50 $250 $275
TRXCENTS (SAVINGS ENABLED TABLET SPLITTING) Through this program, members pay only one-half of their usual copayment on a select group of prescription drugs. This program is part of your pharmacy benefit and is voluntary.
SPECIALTY PHARMACY Navitus SpecialtyRx helps members who are taking medications for certain chronic illnesses or complex diseases by providing services that offer convenience and support. This program is part of your pharmacy benefit and is mandatory.
Specialty In-Network Pharmacy 1-30 Days Supply
Group
Coinsurance Amount
HMO Bronze 003 Off Exchange 40% coinsurance
HMO Bronze 003 40% coinsurance
HMO Bronze 003 Zero Cost Sharing Plan
Variation
$0
HMO Bronze 003 Limited Cost Sharing Plan
Variation
$40% coinsurance
$0 when filled through an Indian Health Service Provider
HMO Silver 002 Off Exchange 50% coinsurance
HMO Silver 002 50% coinsurance
HMO Silver 002 Zero Cost Sharing Plan
Variation
$0
HMO Silver 002 Limited Cost Sharing Plan
Variation
50% coinsurance
$0 when filled through an Indian Health Service Providerr
HMO Silver 002 94 20% coinsurance
HMO Silver 002 87 30% coinsurance
HMO Silver 002 73 50% coinsurance
HMO Silver 004 Off Exchange 45% coinsurance
HMO Silver 004 45% coinsurance
HMO Silver 004 Zero Cost Sharing Plan
Variation
$0
HMO Silver 004 Limited Cost Sharing Plan
Variation
45% coinsurance
$0 when filled through an Indian Health Service Provider
HMO Silver 004 94 20% coinsurance
HMO Silver 004 87 30% coinsurance
HMO Silver 004 73 40% coinsurance
HMO Gold 001 Off Exchange 30% coinsurance
HMO Gold 001 230% coinsurance
HMO Gold 001 Zero Cost Sharing Plan
Variation
$0
HMO Gold 001 Limited Cost Sharing Plan
Variation
30% coinsurance
$0 when filled through an Indian Health Service Provider
HMO Gold 005 Off Exchange 30% coinsurance
HMO Gold 005 30% coinsurance
HMO Gold 005 Zero Cost Sharing Plan
Variation
$0
HMO Gold 005 Limited Cost Sharing Plan
Variation
30% coinsurance
$0 when filled through an Indian Health Service Provider
HMO Gold 006 KelseyCare Off Exchange 30% coinsurance
HMO Gold 006 KelseyCare 30% coinsurance
HMO Gold 006 KelseyCare Zero Cost
Sharing Plan Variation
$0
HMO Gold 006 KelseyCare Limited Cost
Sharing Plan Variation
30% coinsurance
$0 when filled through an Indian Health Service Provider
HMO Silver 007 KelseyCare Off Exchange 50% coinsurance
HMO Silver 007KelseyCare 50% coinsurance
HMO Silver 007 KelseyCare Zero Cost
Sharing Plan Variation
$0
HMO Silver 007 KelseyCare Limited Cost
Sharing Plan Variation
50% coinsurance
$0 when filled through an Indian Health Service Provider
HMO Silver 007 KelseyCare 94 20% coinsurance
HMO Silver 007 KelseyCare 87 30% coinsurane
HMO Silver 007 KelseyCare 73 50% coinsurance