University of Cincinnati Medical Plan Summary and Comparison Non AAUP - Effective January 1- December 31, 2021
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 pharmacy copay per prescription (1): $20 Tier 1: Drugs that offer greatest value including generic versions of brand name drugs. $40 Tier 2: Brand name drugs that are generally more affordable; may
drugs.
$55 Tier 3: Higher cost brand name drugs (may have generic 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.
90- day prescription fills are not available at a retail pharmacy (except CVS).
Mail order (or through CVS retail) for a 90-day supply of maintenance medications see below): $40 Tier 1 $80 Tier 2 $110 Tier 3 Tier 4: 34 day supply available through mail order 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
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