What you pay for prescription drug services

2024	HSA 5000	HSA 2000	PPO 1500	PPO 750	Kaiser HMO (California only)
Annual Deductible (Individual/Employee + One or More)	In-Network: $5,000/$10,000 integrated with medical Out-of-Network: $10,000/$20,000 integrated with medical	In-Network: $2,000/$4,000 integrated with medical Out-of-Network: $4,000/$8,000 integrated with medical	Not applicable	Not applicable	In-Network: $1,500/$3,000 integrated with medical Out-of-Network: Not covered.
Annual Out-of-Pocket Maximum (Employee Only)	In-Network: $7,500 integrated with medical Out-of-Network: $15,000 integrated with medical	In-Network: $5,000 integrated with medical Out-of-Network: $10,000 integrated with medical	In-Network: $5,000 integrated with medical Out-of-Network: $10,000 integrated with medical	In-Network: $3,000 integrated with medical Out-of-Network: $10,000 integrated with medical	In-Network: $4,000 integrated with medical Out-of-Network: Not covered.
Annual Out-of-Pocket Maximum (Employee + Spouse or Employee + Child)	In-Network: $15,000 integrated with medical Out-of-Network: $30,000 integrated with medical	In-Network: $10,000 integrated with medical Out-of-Network: $20,000 integrated with medical	In-Network: $10,000 integrated with medical Out-of-Network: $20,000 integrated with medical	In-Network: $6,000 integrated with medical Out-of-Network: $20,000 integrated with medical	In-Network: $8,000 integrated with medical Out-of-Network: Not covered.
Annual Out-of-Pocket Maximum (Employee + Children or Employee + Family)	In-Network: $15,000 integrated with medical Out-of-Network: $30,000 integrated with medical	In-Network: $10,000 integrated with medical Out-of-Network: $20,000 integrated with medical	In-Network: $15,000 integrated with medical Out-of-Network: $30,000 integrated with medical	In-Network: $9,000 integrated with medical Out-of-Network: $30,000 integrated with medical	In-Network: $8,000 integrated with medical Out-of-Network: Not covered.
Preventive Generic	$10 maximum; no deductible	$10 maximum; no deductible	$15 maximum; no deductible	$10 maximum; no deductible	$0 copay; no deductible
Preventive Brand Formulary	30% coinsurance; no deductible (minimum $35; maximum $70)	30% coinsurance; no deductible (minimum $35; maximum $70)	$60 copay; no deductible	$40 copay; no deductible	$30 copay; no deductible
Preventive Brand Non-Formulary	50% coinsurance; no deductible (minimum $70; maximum $140)	50% coinsurance; no deductible (minimum $70; maximum $140)	$120 copay; no deductible	$80 copay; no deductible	$30 copay; no deductible
Generic Retail (30-Day Supply)	$10 maximum after deductible	$10 maximum after deductible	$15 maximum; no deductible	$10 maximum; no deductible	$10 maximum; no deductible
Brand Formulary Retail (30-Day Supply)	30% coinsurance after deductible (minimum $35; maximum $70)	30% coinsurance after deductible (minimum $35; maximum $70)	$60 copay; no deductible	$40 copay; no deductible	$30 copay; no deductible
Brand Non-Formulary Retail (30-Day Supply)	50% coinsurance after deductible (minimum $70; maximum $140)	50% coinsurance after deductible (minimum $70; maximum $140)	$120 copay; no deductible	$80 copay; no deductible	$30 copay; no deductible
Generic Mail Order (90-Day Supply Anthem) (100-Day Supply Kaiser)	$25 copay after deductible	$25 copay after deductible	$30 copay; no deductible	$20 copay; no deductible	$20 copay; no deductible
Brand Formulary Mail Order (90-Day Supply Anthem) (100-Day Supply Kaiser)	30% coinsurance after deductible (minimum $90; maximum $180)	30% coinsurance after deductible (minimum $90; maximum $180)	$120 copay; no deductible	$80 copay; no deductible	$60 copay; no deductible
Brand Non-Formulary Mail Order (90-Day Supply Anthem) (100-Day Supply Kaiser)	50% coinsurance after deductible (minimum $175; maximum $350)	50% coinsurance after deductible (minimum $175; maximum $350)	$240 copay; no deductible	$160 copay; no deductible	$60 copay; no deductible

A note about preventive medications: Under the HSA 5000 and HSA 2000 options, the deductible does not need to be met for preventive drugs as defined by CVS Caremark in the preventive drug list.