Large group plans coverage

Prescription drug coverage effective on or after Jan. 1, 2021

2021 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%
2021 Providence Formulary P
Rx $10/$15/$45/$75/50%
Rx $10/$15/$60/$80/50%
Rx $10/$20/$75/$100/50%
Rx $10/$15/$30/$30/$30
Rx $15/$30  |  rXtra $15/$30 2021 Providence Formulary A
Rx $15/$45
Rx $15/50%
Value Plan Rx $5/$10/$50/50%
2021 Providence Formulary D
Rx $5/$15/$30/50%
Rx $5/$15/$40/50%
HSA (Aggregate & Embedded) HSA Qualified Plans (6-tier) 2021 Providence Formulary P
HSA Connect (Aggregate & Embedded) HSA Qualified Plans with Safe Harbor (6-tier) 2021 Providence Formulary P-HSA