University of Cincinnati Medical Plan Summary and Comparison Non AAUP - Effective January 1- December 31, 2022
Covered Service
Health Saving Account/HDHP In network & Out-of-network
PPO Traditional Plan In network & Out-of-network
Prescription Drugs (Anthem Rx4)
80% after deductible
Retail/Mail
Generic:
30% ($20 min, $30 max retail/$40 min, $60 max mail order)
Formulary:
30% ($35 min, $55 max retail/$80 min, $110 max mail order)
Non- Formulary: 30% ($55 min, $75 max retail/$110 min, $150 max mail order)
Specialty:
30% ($250 max)
Pharmacy copays apply to Plan Out-of-Pocket Maximum; see Page 1. *Out- of- network subject to co- insurance and deductible. Mandatory Mail Order–your copay will double if you purchase your maintenance meds at a retail pharmacy (other than CVS) after the 2 nd 30 day fill. Anthem Home Delivery is available for maintenance medical purchases.
Diabetic Supplies
80% 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 Rev. 10/2021
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