RX DRUG BENEFITS PPO HSA Only Plan Member Responsibility (Out of Pocket Cost after deductible) Tier 1 Tier 2 Tier 3 30 Day (Retail) $15 50% 50% 90 Day (Mail Order) $30 50% 50% • HMO (with HRA ) & PPO HSA (with HRA ) plans ( Same benefit level) • Rx drug costs will go towards the combined medical/Rx drug member deductible then the HRA will cover any RX copay • PPO HSA Only plan • Rx drug costs will go towards the combined medical/Rx drug member deductible • Since this plan does not utilize the HRA, out of pocket Rx drug costs are still the member’s responsibility after the deductible • All major pharmacies are included • Pharmacy Benefit Manager is CVS Caremark