Suburban Hospital PPO Plan — 2021
Prescription Services and Supplies
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| In-Network Retail Pharmacy (30-day supply) | In-Network Retail Pharmacy (90-day supply) | Mail Order (90-day supply) | |
|---|---|---|---|
| Oral Contraceptives | |||
| Generic | $0 | $0 | $0 |
| Preferred | $40 | $120 | $80 |
| Non-Preferred | $65 | $195 | $130 |
| Specialty Medications | Refer to Preferred/Non-Preferred Brand | Restricted to a 30-day retail supply only | Restricted to a 30-day retail supply only |
| Prescription Drugs | |||
| Generic | $10 | $30 | $20 |
| Preferred | $40 | $120 | $80 |
| Non-Preferred | $65 | $195 | $130 |
| Brand with Generic Equivalent | $65 plus the cost differential between generic and brand | $195 plus the cost differential between generic and brand | $130 plus the cost differential between generic and brand |
| Specialty Medications | Refer to Preferred/Non-Preferred Brand | Restricted to a 30-day retail supply only | Restricted to a 30-day retail supply only |
Revised
September 9, 2022
Group Number
E00070
Plan Codes
Under $50K: JP1, JP2; $50K to $120K: JP3, JP4; $120K and over: JP5, JP6
