Large group plans coverage

Prescription drug coverage effective on or after Jan. 1, 2019

2019 Product  Pharmacy Plan Formulary
Choice
Connect
Option Advantage A
Option Advantage B
Option Advantage AB
Out of Area
Personal Option
Traditional Option

Rx $10/$15/$30/$60/50%
2019 Providence Formulary B
Rx $10/$15/$45/$75/50%
Rx $10/$15/$60/$80/50%
Rx $15/$15/$30/$30/$30
Rx $15/$15/$45/$45/$45
Rx $15/$20/50%/50%/50%
Rx $15/$20/$75/$100/50%
Rx $15/$30  |  rXtra $15/$30 2019 Providence Formulary A
Rx $15/$45
Rx $15/50%  |  rXtra $15/50%
Value Plan Rx $5/$10/$50/50%
2019 Providence Formulary D
Rx $5/$15/$30/50%
Rx $5/$15/$40/50%
HSA HSA Qualified Plans (5-tier) 2019 Providence Formulary B
HSA Qualified Plans with Safe Harbor (5-tier) 2019 Providence Formulary F


Prescription drug coverage effective on or after Jan. 1, 2020

2020 Product  Prescription Drug Plan Formulary
Choice
Connect
Option Advantage Base
Option Advantage Plus (A)
Option Advantage Premium (B)
Out of Area
Personal Option
Traditional Option

Rx $10/$15/$30/$60/50%
2020 Providence Formulary B
Rx $10/$15/$45/$75/50%
Rx $10/$15/$60/$80/50%
Rx $15/$15/$30/$30/$30
Rx $15/$15/$45/$45/$45
Rx $15/$20/50%/50%/50%
Rx $15/$20/$75/$100/50%
Rx $15/$30  |  rXtra $15/$30 2020 Providence Formulary A
Rx $15/$45
Rx $15/50%  |  rXtra $15/50%
Value Plan Rx $5/$10/$50/50%
2020 Providence Formulary D
Rx $5/$15/$30/50%
Rx $5/$15/$40/50%
HSA (Aggregate & Embedded)
HSA Connect (Aggregate & Embedded)
HSA Qualified Plans (5-tier) 2020 Providence Formulary B
HSA Qualified Plans with Safe Harbor (5-tier) 2020 Providence Formulary F