Sibley PPO Plan — 2023
Prescription Services and Supplies
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| In-Network Retail Pharmacy (30-day supply) | In-Network Retail Pharmacy (90-day supply) | Mail Order (90-day supply) | |
|---|---|---|---|
| Oral Contraceptives | |||
| Generic | $0 | $0 | $0 |
| Preferred | $40 | $120 | $80 |
| Non-Preferred | $65 | $195 | $130 |
| Prescription Drugs | |||
| Generic | $10 | $30 | $20 |
| Preferred | $40 | $120 | $80 |
| Non-Preferred | $65 | $195 | $130 |
| Brand with Generic Equivalent | $65 plus the cost differential between generic and brand | $195 plus the cost differential between generic and brand | $130 plus the cost differential between generic and brand |
| Specialty Medications | Refer to Preferred/Non-Preferred Brand | Restricted to a 30-day retail supply only | Restricted to a 30-day retail supply only |
Revised
October 9, 2024
Group Number
E0008500
Plan Codes
Under $50K: JP1C0000; $50K to $120K: JP3C0000; $120K and over: JP5C0000
