2022
2023

Rx Premier – S7126

Premium: $31.40

Deductible: $0 (Tiers 1-2), $480 (Tiers 3-5)

Summary of Benefits

Evidence of Coverage

Rx Premier Formulary

Rx Plus – S7126

Premium: $99.90

Deductible: $480 (All tiers)

Summary of Benefits

Evidence of Coverage

Rx Plus Formulary

Rx Essential

Premium: $18.30

Deductible: $0 (Tier 1), $505 (Tiers 2-5)

Summary of Benefits

Evidence of Coverage

Rx Essential Formulary

Rx Premier

Premium: $59.40

Deductible: $0 (Tiers 1-2), $505 (Tiers 3-5)

Summary of Benefits

Evidence of Coverage

Rx Premier Formulary

Annual Notice of Change (ANOC)