Large group plans coverage

Prescription drug coverage effective on or after Jan. 1, 2018

Medical Plan  Pharmacy Plan Formulary
Open Option
Core Advantages
Personal Option
Choice
Connect
Traditional Option

Rx $0/$10/$15/$20/50%
Providence Formulary B
Rx $0/$15/$20/$30/50%
Rx $0/$15/$20/$45/50%
Rx $0/$20/$25/$40/50%
Rx $0/$25/$30/$50/50%
Rx $10/$15/$30/$60/50%
Rx $10/$15/$45/$75/50%
Rx $10/$15/$60/$80/50%
Rx $15/$20/$75/$100/50%
Rx $15/$20/50%/50%/50%
Rx $15/$15/$30/$30/$30
Rx $15/$15/$45/$45/$45
Rx $10/$20  |  rXtra $10/$20 Providence Formulary A
Rx $10/$30  | rXtra $10/$30
Rx $10/50%  |  rXtra $10/50%
Rx $15/$30  |  rXtra $15/$30
Rx $15/$45  |  rXtra $15/$45
Rx $15/50%  |  rXtra $15/50%
Rx $15/$60  |  rXtra $15/$60
Rx $15/$75
Rx $20/$40
Value Plan Rx $5/$10/$50/50%
Providence Formulary D
Rx $5/$15/$30/50%
Rx $5/$15/$40/50%
HSA HSA Qualified Plans (5-tier) Providence Formulary B
HSA Qualified Plans with Safe Harbor (5-tier) Providence Formulary F
HSA Qualified Plans  (2-tier) Providence Formulary A
HSA Qualified Plans with Safe Harbor
(2-tier)
Providence Formulary E