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Medicare Plans
CCPOA Medical Plan Medicare (PPO)
Western Health Advantage MyCare Select (HMO)
UnitedHealthcare Group Medicare Advantage Edge (PPO)
PERS Gold
PERS Platinum
CAHP Medicare Supplement (Association Plan)
PORAC (Association Plan)
PPO Non PPO
PPO Non PPO
BENEFITS
Prescription Drugs
Deductible
N/A
N/A
N/A
N/A
N/A
N/A
$100
Retail Pharmacy (30-day supply)
Generic: $5 Formulary: $20 Non Formulary: $50 Generic: $5 Formulary: $20 Non Formulary: $50 Generic: $10 Formulary: $40 Non Formulary: $100
Generic: $10 Preferred: $25 Non Preferred: $45
Tier 1: $5 Tier 2: $20 Tier 3: $35 Tier 4: $50
Tier 1: $5 Tier 2: $20 Tier 3: $50
Tier 1: $5 Tier 2: $20 Tier 3: $50
Tier 1: $5 Tier 2: $20 Tier 3: $50
Tier 1: $5 Tier 2: $20 Tier 3: $50
Retail Preferred Pharmacy Maintenance Medication (90-day supply)
Tier 1: $10 Tier 2: $40 Tier 3: $70 Tier 4: N/A
Tier 1: $10 Tier 2: $40 Tier 3: $100
Generic: $10 Preferred: $40 Tier 3: $100
Tier 1: $10 Tier 2: $40 Tier 3: $100
Tier 1: $10 Tier 2: $40 Tier 3: $100
N/A
Generic: $20 Preferred: $40 Non Preferred: $75
Mail Order Pharmacy Program (not to exceed 90-day supply for maintenance drugs)
Tier 1: $10 Tier 2: $40 Tier 3: $70 Tier 4: N/A
Tier 1: $10 Tier 2: $40 Tier 3: $100
Tier 1: $10 Tier 2: $40 Tier 3: $100
Tier 1: $10 Tier 2: $40 Tier 3: $100
Tier 1: $10 Tier 2: $40 Tier 3: $100
Mail order maximum copayment per person per calendar year
$1,000
$1,000
N/A
$1,000
$1,000
N/A
N/A
Occupational / Physical / Speech Therapy
Inpatient (hospital or skilled nursing facility) Outpatient (office and home visits)
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
Diabetes Services
Glucose monitors
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
$25
1 Of the allowed amount 2 See EOC for additional details
2023 Health Benefit Summary | 29
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