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MedImpact - PPO

Prescription Maximum Calendar Year Out-of-pocket

Maximum Calendar Year Out-of-pocket Plan A
In-Network		 Plan A
Out-of-Network		 Plan B
In-Network		 Plan B
Out-of-Network
Individual $400 N/A $900 N/A
Family $800 N/A $1,800 N/A

Retail and Mail Order Prescription (30-day Supply)

Tiers Plan A
In-Network		 Plan A
Out-of-Network		 Plan B
In-Network		 Plan B
Out-of-Network
Tier 1 Generic Prescription $0 Copay Not Covered $0 Copay Not Covered
Tier 2 Generic Prescription $10 Copay Not Covered $10 Copay Not Covered
Tier 3 Preferred Brand Name $35 Copay Not Covered $35 Copay Not Covered
Tier 4 Non-Preferred Brand Name $50 Copay Not Covered $50 Copay Not Covered

Retail and Mail Order Prescription (90-day Supply)

Tiers Plan A
In-Network		 Plan A
Out-of-Network		 Plan B
In-Network		 Plan B
Out-of-Network
Tier 1 Generic Prescription $0 Copay Not Covered $0 Copay Not Covered
Tier 2 Generic Prescription $20 Copay Not Covered $20Copay Not Covered
Tier 3 Preferred Brand Name $70 Copay Not Covered $70 Copay Not Covered
Tier 4 Non-Preferred Brand Name $100 Copay Not Covered $100 Copay Not Covered