Explore a Plan:

Suburban Hospital PPO Plan — 2021

Print
Sorry, no results.
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 MedicationsRefer to Preferred/Non-Preferred BrandRestricted to a 30-day retail supply onlyRestricted 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 MedicationsRefer to Preferred/Non-Preferred BrandRestricted to a 30-day retail supply onlyRestricted 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
Available 24/7

HealthLINK gives you 24/7 access to your health plan. View your Explanation of Benefits (EOBs), check claim status, change your primary care doctor, update your personal information and more.

/>
Scroll to Top