Page 11 - GXO 2022 OE Guide-Active
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What you pay for services
12
DEDUCTIBLE
Individual
Generic
Brand Non-Formulary
RETAIL (30-DAY SUPPLY)
Generic
Brand Non-Formulary
Basic HSA HSA Plus
$2,500 Basic HSA $1,750 HSA Plus (integrated with medical)
$10 maximum; no deductible 50%; no deductible
(minimum $70; maximum $140) $10 maximum after deductible
50% after deductible (minimum $70; maximum $140)
Basic PPO Classic PPO
Not Applicable
$10 maximum; no deductible 50%; no deductible
(minimum $70; maximum $140) $10 maximum; no deductible
50%; no deductible (minimum $70; maximum $140)
$25 copay; no deductible 50%; no deductible
(minimum $175; maximum $350)
Employee + One or More
$5,000 Basic HSA $3,500 HSA Plus (integrated with medical)
Not Applicable
PREVENTIVE
Brand Formulary
30%; no deductible (minimum $35; maximum $70)
30%; no deductible (minimum $35; maximum $70)
Brand Formulary
30% after deductible (minimum $35; maximum $70)
30%; no deductible (minimum $35; maximum $70)
MAIL ORDER (90-DAY SUPPLY)
Generic
Brand Non-Formulary
$25 copay after deductible 50% after deductible
(minimum $175; maximum $350)
Brand Formulary
30% after deductible (minimum $90; maximum $180)
30%; no deductible (minimum $90; maximum $180)
Prescription Drugs I 9
