7 / 20
6
Prescription Drugs
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 Aetna PPO plan.
Aetna PPO (CA and Non-CA)
In-Network
Out-Of-Network
Pharmacy
Generic
$10 copay
$10 copay + plan pays 80% of
billed charges
Preferred Brand
$25 copay
$25 copay + plan pays 80% of
billed charges
Non-preferred Brand
$45 copay
$45 copay + plan pays 80% of
billed charges
Specialty Drug
You are responsible for 30% up to
$200
N/A
Supply Limit
up to a 30-day supply
up to a 30-day supply
Mail Order
Generic
$20 copay
Not covered
Preferred Brand
$50 copay
Not covered
Non-preferred Brand
$90 copay
Not covered
Supply Limit
up to a 90 day-supply
N/A