| HSA Plus | HSA Basic | PPO* | ||||
|---|---|---|---|---|---|---|
| In-Network | Out-of-Network | In-Network | Out-of-Network | In-Network | In-Network | |
| Prescription Drugs:** | ||||||
| Retail (30-day) | ||||||
| Preventive | 100% generic only (If no generic is available, the brand-name preventive prescription drug will be paid at 100%.) | Covered the same as any other prescription drug | ||||
| Tier 1 | 90% after deductible | 80% after deductible | $15 copay | |||
| Tier 2 | 70% ($30 min/$100 max) | |||||
| Tier 3 | 50% ($50 min/$200 max) | |||||
| Mail (90-day) | ||||||
| Preventive | 100% generic only (If no generic is available, the brand-name preventive prescription drug will be paid at 100%.) | Covered the same as any other prescription drug | ||||
| Tier 1 | 90% after deductible | 80% after deductible | $30 copay | |||
| Tier 2 | 70% ($60 min/$250 max) | |||||
| Tier 3 | 50% ($100 min/$400 max) | |||||
*PPO only: Prescription drug costs apply to out-of-pocket maximum, not deductible. **All prescription drugs must be FDA approved to be covered. If a generic drug is available and you elect to purchase the brand-name drug instead, you will pay the difference between the generic and brand-name drug cost. If your doctor prescribes a brand-name drug, or if no generic is available, brand-name prescription drug will be paid per the plan. For some conditions, you may be required to try an equivalent but lower-cost drug first. | ||||||