Prescription Drugs (Express Scripts)

Prescription Drugs (Express Scripts)
Prescription drug coverage provides a benefit that is important to your overall health, whether you need a
prescription for a short-term health issue like bronchitis or an ongoing condition like high blood pressure.
Delta Health Systems (Anthem Blue
Cross Network) Medical PPO Plan A
Delta Health Systems (Anthem Blue
Cross Network) Medical PPO Plan B
In-Network
Out-Of-Network
In-Network
Out-Of-Network
$4,600 Individual
$7,200 Family
$4,600 Individual
$7,200 Family
$3,350 Individual
$6,700 Family
$3,350 Individual
$6,700 Family
Generic
$5 copay
$5 copay
$10 copay
$10 copay
Preferred Brand
Plan pays 50% to
$30 copay
maximum per
prescription
Plan pays 50% to
$30 copay
maximum per
prescription
Plan pays 50% to
$40 copay
maximum per
prescription
Plan pays 50% to
$40 copay
maximum per
prescription
Non-preferred Brand
Plan pays 50% to
$80 copay
maximum per
prescription
Plan pays 50% to
$80 copay
maximum per
prescription
Plan pays 50% to
$100 copay
maximum per
prescription
Plan pays 50% to
$100 copay
maximum per
prescription
Supply Limit
30 days
30 days
30 days
30 days
Generic
$10 copay
Not covered
$20 copay
Not covered
Preferred Brand
Plan pays 50% to
$60 copay
maximum per
prescription
Not covered
Plan pays 50% to
$80 copay
maximum per
prescription
Not covered
Non-preferred Brand
Plan pays 50% to
$160 copay
maximum per
prescription
Not covered
Plan pays 50% to
$200 copay
maximum per
prescription
Not covered
Supply Limit
90 days
Not applicable
90 days
Not applicable
Annual Out-of-Pocket
Limit
Pharmacy
Mail Order
12