Suburban Hospital EPO Plan — 2023
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 | 25%; $40 min; $60 max | 25%; $120 min; $180 max | 25%; $120 min; $180 max |
| Non-Preferred | 50%; $65 min; $105 max | 50%; $195 min; $315 max | 50%; $195 min; $315 max |
| Prescription Drugs | |||
| Generic | $10 | $30 | $30 |
| Preferred | 25%; $40 min; $60 max | 25%; $120 min; $180 max | 25%; $120 min; $180 max |
| Non-Preferred | 50%; $65 min; $105 max | 50%; $195 min; $315 max | 50%; $195 min; $315 max |
| Brand with Generic Equivalent | 50%; $65 min; $105 max, plus the cost differential between generic and brand | 50%; $195 min; $315 max, plus the cost differential between generic and brand | 50%; $195 min; $315 max, plus the cost differential between generic and brand |
Revised
December 21, 2022
Group Number
E0007000
Plan Codes
JE1C0000
