| Plan Name |
Prescription Benefit Plan Options |
| HSAH1500 - 20% |
- 50018 - 5 Tier $10/25/50/50/80
- 50216 - 5 Tier $20/40/60/60/100
- 50508 - Deductible then 50% Co-insurance
|
| HSAH2000 - 20% |
- 50020 - 5 Tier $10/25/50/50/80
- 50218 - 5 Tier $20/40/60/60/100
- 50510 - Deductible then 50% Co-insurance
|
| HSAH2500 - 20% |
- 50022 - 5 Tier $10/25/50/50/80
- 50220 - 5 Tier $20/40/60/60/100
- 50512 - Deductible then 50% Co-insurance
|
| HSAH3000 - 20% |
- 50024 - 5 Tier $10/25/50/50/80
- 50222 - 5 Tier $20/40/60/60/100
- 50514 - Deductible then 50% Co-insurance
|
| HSAH3500 - 20% |
- 50046 - 5 Tier $10/25/50/50/80
- 50224 - 5 Tier $20/40/60/60/100
- 50524 - Deductible then 50% Co-insurance
|
| HSAH4000 - 20% |
- 50048 - 5 Tier $10/25/50/50/80
- 50226 - 5 Tier $20/40/60/60/100
- 50526 - Deductible then 50% Co-insurance
|
| HSAH4500 - 20% |
- 50050 - 5 Tier $10/25/50/50/80
- 50228 - 5 Tier $20/40/60/60/100
- 50528 - Deductible then 50% Co-insurance
|
| HSAH5000 - 20% |
- 50052 - 5 Tier $10/25/50/50/80
- 50230 - 5 Tier $20/40/60/60/100
- 50530 - Deductible then 50% Co-insurance
|
