2018 Nevada County Benefit Summary

13 / 32

12
Prescription Drugs - PPO and PORAC
Anthem Blue Cross
Choice & Select PPO
Anthem Blue Cross
PERS Care PPO
Anthem Blue Cross
PORAC PPO
In-Network In-Network In-Network
Prescription Drug
Deductible
$0 $0 $0
Pharmacy 1
Generic $5 copay $5 copay $10 copay
Preferred Brand $20 copay $20 copay $25 copay
Non-preferred Brand $50 copay $50 copay $45 copay
Supply Limit 30 days 30 days 30 days
Mail Order & After 1st
Fill
Generic $10 copay $10 copay $20 copay
Preferred Brand $40 copay $40 copay $40 copay
Non-preferred Brand $100 copay $100 copay $75 copay
Supply Limit 90 days 90 days 90 days
Mail Order Annual
Out-of-Pocket Limit
$1,000 $1,000 N/A
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.