Supplemental benefits include:
- Prescription Drug
- Vision
- Dental
- Hearing Aid
Prescription Drug Plan
- Prescription drug coverage for you and your eligible dependents
- Three-tier copayment plan
- Retail (up to 30-day supplies) and maintenance (up to 90-day supplies) programs
| Prescriptions at a Network Pharmacy – up to a 30 Day Supply |
Your Copayment |
| Tier 1: Generic drug |
$15 |
| Tier 2: Preferred brand-name drug |
$40, plus the cost difference between the brand and the generic, if one exists |
| Tier 3: Non-Preferred brand-name drug |
$80, plus the cost difference between the brand and the generic, if one exists |
| Mail Order and CVS Pharmacy – up to a 90 Day Supply |
Your Copayment |
| Tier 1: Generic drug |
$22.50 |
| Tier 2: Preferred brand-name drug |
$60, plus the cost difference between the brand and the generic, if one exists |
| Tier 3: Non-Preferred brand-name drug |
$120, plus the cost difference between the brand and the generic, if one exists |
| Retail Maintenance at a Rite Aid Pharmacy – up to 90 Day Supply |
Your Copayment |
| Tier 1: Generic drug |
$30 |
| Tier 2: Preferred brand-name drug |
$80, plus the cost difference between the brand and the generic, if one exists |
| Tier 3: Non-Preferred brand-name drug |
$160, plus the cost difference between the brand and the generic, if one exists |
Vision Plan
- Yearly vision exam allowance
- Standard lenses allowance (once per year)
- Frames (every two years)
Dental Plan
- Fee-for-service dental plan
Hearing Aid Plan
- Hearing aid reimbursement allowance – limited to every 36 months
For more information, refer to the Summary Plan Description or the Prescription Drug Formulary.
