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Sibley PPO Plan — 2022

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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
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