2020-2021 Benefits Guide rev 6.22.2021

Prescription Drug Program

Humana NPOS

Humana HDHP

IN-NETWORK

OUT-OF-NETWORK

IN-NETWORK

OUT-OF-NETWORK

Retail Prescription (copays per 30-day supply)

Deductible does not apply

Level 1: Generic / Brand Drugs - Low Cost Level 2: Generic / Brand Drugs - Higher Cost Level 3: Brand Drugs - High Cost Level 4: Highest Cost Drugs MAIL SERVICE PRESCRIPTION (copays per 90-day supply) Level 1: Generic / Brand Drugs - Low Cost Level 2: Generic / Brand Drugs - Higher Cost Level 3: Brand Drugs - High Cost Level 4: Highest Cost Drugs Specialty Drugs

$10 copay

30% coinsurance

$40 copay

100% after cal yr deductible

30% coinsurance

$70 copay

25% coinsurance

25%/35% coinsurance

50% coinsurance

$25 copay

$100 copay

30% coinsurance

100% after cal yr deductible

30% coinsurance

$175 copay

25% coinsurance

Specialty Drug

NA

NA

NOTE:

Hearing aids apply only up to age 19

12