2018 Nevada County Benefit Summary

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Prescription Drugs - HMO
Prescription drug coverage provides a benefit that is important to your overall health, whether you need a
prescription for a short-term health issue like bronchitis or an ongoing condition like high blood pressure.
If you enroll in medical coverage, you will automatically receive coverage for prescription drugs. Here are the
prescription drug plans that are offered with our CalPERS Medical plans.
Anthem Blue
Cross HMO
Blue Shield
Access+
HealthNet
SmartCare
Kaiser
Permanente
United
HealthCare
HMO
In-Network In-Network In-Network In-Network In-Network
Prescription Drug
Deductible
$0 $0 $0 $0 $0
Pharmacy 1
Generic $5 copay $5 copay $5 copay $5 copay $5 copay
Formulary $20 copay $20 copay $20 copay $20 copay $20 copay
Non-Formulary $50 copay $50 copay $50 copay $20 copay $50 copay
Supply Limit 30 days 30 days 30 days 30 days 30 days
Mail Order & After 1st
Fill
Generic $10 copay $10 copay $10 copay $10 copay $10 copay
Formulary $40 copay $40 copay $40 copay $40 copay $40 copay
Non-Formulary $100 copay $100 copay $100 copay $100 copay $100 copay
Supply Limit 90 days 90 days 90 days 100 days 90 days
Mail Order Annual
Out-of-Pocket Limit
$1,000 $1,000 $1,000 N/A $1,000
11st Fill Only
Specific details and plan limitations are provided in the Summary Plan Description (SPD), which is based on the official Plan Documents
that may include policies, contracts, and plan procedures. The SPD and Plan Documents contain all the specific provisions of the plans. In
the event that the information in this summary differs from the Plan Documents, the Plan Documents will prevail.