Prescription Benefit Summaries: FreestandingGroups 100+

Standard | Select | Deductible/Coinsurance

Forms are in pdf format.

Option
20%
50%
$2/$10
$5/$10
$5/$15
$5/$20
$6/$10
$10/$15
$10/$20
$4 Generic Only/Brand Discount Standard Drug
$7 Generic/50% with $125 Max Brand Standard Drug
$7 Generic/50% with $250 Max Brand Standard Drug
$7 Generic Only/Brand Discount Standard Drug