| Plan provision |
Health Reimbursement Copay Advantage Plan |
Health Savings Medical Plan* |
Kaiser HMO Medical Plan |
| Annual deductible |
None |
You must pay 100% of the cost of prescription drugs until you meet the combined medical and prescription drug deductible.
In-network
Medical and prescription drug combined
$2,000 individual
$4,000 family
Out-of-network
Medical and prescription drug combined
$3,000 individual
$6,000 family
|
None |
| Out-of-pocket maximum |
$2,300 per individual; limited to $3,500 per family |
Medical and prescription drug combined
$4,500 individual
$9,000 family* |
None |
| Retail (30-day supply) |
- Generic: $10**
- Preferred brand: $50
- Non-preferred brand: $100
|
- Generic: 10% ($5 minimum; $25 maximum)**
- Preferred brand: 30% ($20 minimum; $100 maximum)
- Non-preferred brand: 45% ($35 minimum; $150 maximum)
|
- Generic: $15
- Preferred brand: $30
- Non-preferred brand: $30
|
| Mail order service or CVS pharmacy (90-day supply) |
- Generic: $20**
- Preferred brand: $100
- Non-preferred brand: $200
|
- Generic: 10% ($10 minimum; $50 maximum)**
- Preferred brand: 30% ($40 minimum; $200 maximum)
- Non-preferred brand: 45% ($70 minimum; $300 maximum)
|
- Generic: $30
- Preferred brand: $60
- Non-preferred brand: $60
|
| Specialty† medications (30-day supply) |
- 30%; no minimum copay; $300 maximum (excludes drugs eligible for PrudentRX program)
|
- 30% after deductible is met; no minimum copay; $300 maximum (excludes drugs eligible for PrudentRX program)
|
- $30 per prescription (up to a 30-day retail supply and subject to formulary guidelines)
|
* If an employee covers more than one individual under the Health Savings Medical Plan, and one individual reaches $7,350 in eligible in-network out-of-pocket expenses, all remaining eligible in-network expenses will be paid at 100% for that individual only.
** If the total cost of the drug is less than the flat copay or minimum amount, you’ll pay only the full cost of the drug.
† PrudentRx Copay Program: Siemens Healthineers has contracted with PrudentRx to offer the PrudentRx Copay Program for certain specialty medications. The PrudentRx Copay Program assists members by helping them enroll in manufacturer copay assistance programs. Medications on the plan’s specialty drug list and exclusively dispensed by CVS Specialty are included in the program and will be subject to 30% coinsurance (subject to deductible). However, members enrolled in PrudentRx who get a copay card for their specialty medication (if applicable) or who are taking a specialty medication for which no copay card is available will have a $0 out-of-pocket responsibility after deductible, for their prescriptions covered under the PrudentRx Copay Program.
