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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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