University of Cincinnati Medical Plan Summary and Comparison AAUP - Effective January 1- December 31, 2022
Covered Service
Health Saving Account/HDHP In network
Health Saving Account/HDHP Out-of-network
PPO Traditional Plan In network & Out-of-network
Prescription Drugs (Anthem Rx4)
90% after deductible
70% after deductible
Retail pharmacy copay per prescription(1): • $15 Tier 1: Drugs that offer greatest valueincluding generic versions of brand namedrugs. • $25 Tier 2: Brand name drugs that are generally more affordable; may also include ‘preferred’ drugs. • $35 Tier 3: Higher cost brand name drugs (may havegeneric version Tier 1). • Tier 4: 25% co-insurance ($250 per prescription/purchase maximum) – specialty drugs used to treat chronic conditions; may require special handling or management.
Mail order for a 90-day supply: • $30 Tier 1 • $50 Tier 2 • $70 Tier 3 • Tier 4: 34 day supply available through mailorder
Pharmacy copays apply to Plan Out-of-Pocket Maximum; see Page 1. *Out-of- Network subject to co-insurance and deductible.
Diabetic Supplies
90% after deductible
80% diabetic supplies such as lancets, pen needles, test strips and autolet devices. Excludes drugs not requiring a prescription (except injectable insulin), drugs administered while hospitalized or covered by Workers’ Compensation, and therapeutic devices and appliances.
Page 5 of 7 10-2021 rev.
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