Remember Maintenance medications after your second fill must be purchased at a CVS pharmacy or through CVS Mail Service Pharmacy. AB = Allowed Benefit This chart contains highlights only and is subject to change. The specific terms of coverage, exclusions and limitations are contained in the Summary Plan Description, the Group Benefit Guide or the Group Service Agreement. AB—Allowed Benefit. AWP—Average Wholesale Price. Medical Benefits Options Triple Option CareFirst BlueCross BlueShield Preferred Provider Organization CORE Xxxxx 0 XxxxXxxxx XxxxXxxxxx PPO Providers Level 3 Participating and Non-participating Providers In-network BlueCross BlueShield PPO Providers Out-of-network Participating and Non-participating Providers 100% AB Paid as Xxxxx 0 90% AB Paid as in-network $25 copay 80% AB $25 copay 70% AB 100% AB 80% AB 90% AB (no deductible) 70% AB 100% AB 80% AB 90% AB 70% AB 100% AB 80% AB 90% AB 70% AB $20 copay 80% AB $20 copay (no deductible) 70% AB $5,400 Individual / $10,800 Family $4,200 Individual / $8,400 Family $15 copay Generic drug (Tier 1) $30 copay Preferred Brand (Tier 2) $45 copay Non-preferred Brand (Tier 3) Maintenance medication up to 90 day supply 1 times retail at CVS only: $15 copay—Generic drug (Tier 1) $30 copay—Preferred Brand (Tier 2) $45 copay—Non-preferred Brand (Tier 3) $15 copay Generic drug (Tier 1) $30 copay Preferred Brand (Tier 2) $45 copay Non-preferred Brand (Tier 3) Maintenance medication up to 90 day supply 1 times retail at CVS only: $15 copay—Generic drug (Tier 1) $30 copay—Preferred Brand (Tier 2) $45 copay—Non-preferred Brand (Tier 3) CVS Caremark Mail Order Prescription Program for maintenance medication 1 times copay—Up to 90 day supply $15 copay—Generic drug (Tier 1) $30 copay—Preferred Brand (Tier 2) $45 copay—Non-preferred Brand (Tier 3) CVS Caremark Mail Order Prescription Program for maintenance medication 1 times copay—Up to 90 day supply $15 copay—Generic drug (Tier 1) $30 copay—Preferred Brand (Tier 2) $45 copay—Non-preferred Brand (Tier 3) 100% AB 100% AB 100% AB 100% AB * Precertification required or penalties may apply. ** Mandatory generic substitution—see the CareFirst Drug Program section on page 20. CareFirst Drug Program Summary of Benefits Formulary 2 Plan Feature BlueChoice HMO Open Access Triple Option PPO CORE Description Deductible None None None Your benefit does not have a deductible. Prescription Drug Out-of-Pocket Maximum $6,600 Individual/ $13,200 Family $5,400 Individual/ $10,800 Family $4,200 Individual/ $8,400 Family Your benefit does not have a family deductible maximum. Preventive Drugs (up to a 34-day supply) $0 (not subject to deductible) $0 (not subject to deductible) $0 (not subject to deductible) A preventive drug is a prescribed medication or item on CareFirst’s Preventive Drug List.* Oral Chemotherapy & Diabetic Supplies (up to a 34-day supply) $0 $0 $0 Diabetic supplies include needles, lancets, test strips and alcohol swabs. Generic Drugs (Tier 1) (up to a 34-day supply) $10 $15 $15 Generic drugs are covered at this copay level . Preferred Brand Drugs (Tier 2) (up to a 34-day supply) $20 $30 $30 All preferred brand drugs are covered at this copay level. Non-Preferred Brand Drugs (Tier 3) (up to a 34-day supply) $40 $45 $45 All non-preferred brand drugs on this copay level are not on the Preferred Drug List.* Discuss using alternatives with your physician or pharmacist. Maintenance Copays (up to a 90-day supply) Maintenance medication must be purchased at a CVS pharmacy or through Mail Service for a 90-day supply. Retail (CVS only): Generic $20 $15 $15 Preferred $40 $30 $30 Non-preferred $80 $45 $45 Mail Order: Generic $20 $15 $15 Preferred $40 $30 $30 Non-preferred $80 $45 $45 Prior Authorization Some prescription drugs require Prior Authorization. Prior Authorization is a tool used to ensure that you will achieve the maximum clinical benefit from the use of specific targeted drugs. Your physician or pharmacist must call (000) 000-0000 to begin the prior authorization process. For the most up-to-date prior authorization list, visit the prescription drug website at xxxxxxxxx.xxx/xxxxxxx . Mandatory Generic Substitution If you choose a Non-preferred Brand drug (Tier 3) instead of its Generic equivalent, you will pay the highest copay plus, the difference in cost between the Non-preferred Brand drug and the Generic. If a Generic version is not available, you will only pay the copay. Delta Dental Plan Benefit Highlights for: Harford County Public Schools Group No: 00528 - PPO - Comprehensive Eligibility Primary enrollee, spouse and eligible dependent children to the end of the month dependent turns age 26 Deductibles Deductibles waived for Diagnostic & Preventive (D & P) and Orthodontics? Delta Dental PPO dentists: $25 per person / $50 per family each plan year Non-Delta Dental PPO dentists: $50 per person / $150 per family each plan year Yes Maximums D & P counts toward maximum? $1,500 per person each plan year No Waiting Period(s) Basic Benefits None Major Benefits None Prosthodontics None Orthodontics None Benefits and Covered Services* Delta Dental PPO dentists** Non-Delta Dental PPO dentists** Diagnostic & Preventive Services Exams, cleanings, x-rays and sealants 100 % 65 % Surgical Removal of Impacted Teeth 100 % 65 % Basic Services Fillings, denture repair/relining, stainless steel crowns, bridges, bridge recementation/repair and posterior composite restorations 80 % 50 % Endodontics (root canals) Covered Under Basic Services 80 % 50 % Periodontics (gum treatment) Covered Under Basic Services 80 % 50 % Oral Surgery Covered Under Basic Services 80 % 50 % Major Services Crowns, inlays, onlays and cast restorations 50 % 30 % Prosthodontics Dentures 50 % 30 % Implants Covered only as an alternative to a fixed bridge 80 % 50 % Orthodontic Benefits Dependent children to age 19 50 % 50 % Orthodontic Maximums $800 Lifetime $800 Lifetime * Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan. Reimbursement is based on Delta Dental maximum contract allowances and not necessarily each dentist’s submitted fees. ** Reimbursement is based on PPO contracted fees for PPO dentists, PPO contracted fees for Premier dentists and PPO contracted fees for non-Delta Dental dentists. Delta Dental of Pennsylvania Xxx Xxxxx Xxxxx Xxxxxxxxxxxxx, XX 00000 Customer Service 800-932-0783 xxxxxxxxxxxxxx.xxx Claims Address X.X. Xxx 0000 Xxxxxxxxxxxxx, XX 00000-0000 This benefit information is not intended or designed to replace or serve as the plan’s Evidence of Coverage or Summary Plan Description. If you have specific questions regarding the benefits, limitations or exclusions for your plan, please consult your company’s benefits representative. HLT_PPO_2COL_DDP (Rev. 4/17/2017) Delta Dental Plan Benefit Highlights for: Harford County Public Schools Group No: 00528 - PPO Plus Premier - Standard Eligibility Primary enrollee, spouse and eligible dependent children to the end of the month dependent turns age 26 Deductibles Deductibles waived for Diagnostic & Preventive (D & P)? $25 per person / $50 per family each plan year Yes Maximums D & P counts toward maximum? $1,500 per person each plan year No Waiting Period(s) Basic Benefits None Major Benefits None Prosthodontics None Benefits and Covered Services* Delta Dental PPO dentists** Non-Delta Dental PPO dentists** Diagnostic & Preventive Services Exams, cleanings, x-rays and sealants 100 % 100 % Basic Services Fillings, stainless steel crowns and posterior composite restorations 100 % 100 % Endodontics (root canals) 100 % 100 % Oral Surgery 100 % 100 % Periodontics (gum treatment) 0 % 0 % Major Services Crowns, inlays, onlays and cast restorations 0 % 0 % Prosthodontics Bridges and dentures 0 % 0 % * Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan. Reimbursement is based on Delta Dental maximum contract allowances and not necessarily each dentist’s submitted fees. ** Reimbursement is based on PPO contracted fees for PPO dentists, Premier contracted fees for Premier dentists and Premier contracted fees for non-Delta Dental dentists. Delta Dental of Pennsylvania Xxx Xxxxx Xxxxx Xxxxxxxxxxxxx, XX 00000 Customer Service 800-932-0783 Claims Address X.X. Xxx 0000 Xxxxxxxxxxxxx, XX 00000-0000 xxxxxxxxxxxxxx.xxx This benefit information is not intended or designed to replace or serve as the plan’s Evidence of Coverage or Summary Plan Description. If you have specific questions regarding the benefits, limitations or exclusions for your plan, please consult your company’s benefits representative. HLT_PPO_2COL_DDP (Rev. 4/17/2017) Benefit Plan Resources
