Active Members: Supplemental Benefits

Enrollee Type: Active Member
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Supplemental benefits include:

Prescription Drug Plan

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

Dental Plan

Hearing Aid Plan

For more information, refer to the Summary Plan Description or the Prescription Drug Formulary.