2023
2024

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)

Essential Plan

Premium: $23.00

Deductible: $0 (Tier 1), $545 (Tiers 2-5)

Summary of Benefits

Evidence of Coverage

Essential Plan Formulary

Annual Notice of Change (ANOC)

Premier Plan

Premium: $83.00

Deductible: $0 (Tiers 1-2), $349 (Tiers 3-5)

Summary of Benefits

Evidence of Coverage

Premier Plan Formulary

Annual Notice of Change (ANOC)