CODAC 2024 Benefit Summaries and Carrier Materials

What You Will Pay

Common Medical Event

Limitations, Exceptions, & Other Important Information

Services You May Need

In-network (You will pay the least) Retail: $10 copay after deductible Mail-Order: $25 copay after deductible Retail: $30 copay after deductible Mail-Order: $75 copay after deductible Retail: $50 copay after deductible Mail-Order: $125 copay after deductible Retail: $50 copay after deductible Mail-Order: $50 copay after deductible

Out-of-network (You will pay the most)

Retail: Up to a 31 day supply Mail-Order: Up to a 90 day supply 90 day supply at CVS retail pharmacy subject to Mail-Order copay. Specialty drugs 31 day supply regardless of retail or mail order. You may need to obtain certain drugs, including certain specialty drugs, from a pharmacy designated by CVS/Caremark. For eligible specialty medications, after deductible, $0 copay if filled through the PrudentRx program. If you opt out you will pay 30% of the cost after deductible. Certain drugs may have a prior authorization requirement. Not all drugs are covered. If you use a non-network pharmacy, you are responsible for any amount over the allowed amount. Certain preventive medications are covered at No Charge. Preauthorization is required. If you don’t get preauthorization, a penalty of $250 may be applied.

Retail: $10 copay + amount over allowed amount after deductible

Generic drugs (Tier 1)

If you need drugs to treat your illness or condition. More information about prescription drug coverage is available at www.caremark. com & www.prudentrx. com..

Retail: $30 copay + amount over allowed amount after deductible

Preferred brand drugs (Tier 2)

Retail: $50 copay + amount over allowed amount after deductible

Non-preferred brand drugs (Tier 3)

Retail: $50 copay + amount over allowed amount after deductible

Specialty drugs (Tier 4)

Facility fee (e.g., ambulatory surgery center)

20% Coinsurance

Not covered

If you have outpatient surgery If you need immediate medical attention

Physician/surgeon fees

20% Coinsurance

Not covered

In-network deductible applies to Out-of-network benefits

Emergency room care

20% Coinsurance

20% Coinsurance

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