Sibley PPO Plan — 2022
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
December 1, 2022
Group Number
E0008500
Plan Codes
Under $50K: JD1C0000; $50K to $120K: JD3C0000; $120K and over: JD5C0000