Stages of Pharmacy Coverage

There are three pharmacy coverage stages, but most people stay in the initial coverage stage.

$4,430

$7,050 Most people stay in this range

Few people reach this stage

Even fewer people reach this stage

Initial Coverage You pay the following until the amount you pay plus the amount we pay reaches $4,430:

• Tier 1: $2. • Tier 2: $15. • Tier 3: $47. • Tier 4: 50%. • Tier 5: 33%.*

Coverage Through the Gap If your total prescription spend adds up to $4,430, you’ll reach the coverage gap. With your Reid Health Alliance plan, you’ll continue to pay your copay for Tier 1 medications until your out-of-pocket expenses reach $7,050. Coverage Gap Also known as the “donut hole,” this stage begins when the amount you pay plus the amount we pay for your prescription drugs reaches $4,430. Here, you pay the following until you reach $7,050

• 25% for covered generic drugs. • 25% for covered brand-name drugs. Catastrophic Coverage This stage begins when your out-of-pocket drug costs reach $7,050. Here, we pay for most of your drug costs for the rest of the year, while you pay the greater of the following:

• 5% of the cost. or • $3.95 for covered generic drugs (including brand-name drugs treated as generic) and $9.85 for covered brand-name drugs.

*31% for the POS Rx Basic and HMO Basic Rx 2 plans. For the POS Basic Rx and HMO Basic Rx 2 plans, you must first pay the $100 deductible for drugs on Tiers 3–5, then you pay the copays listed above.