HMO
$10/$20/$35 Mail Order $20/$40/$105	$10/$25/$45 Mail Order $20/$50/$135	$10/$30/$60 Mail Order $20/$60/$180
HDHP HMO ONLY Prescription drugs are subject to the combined Medical/Pharmacy deductible for HNE WisePlus and HNE WiseMax.		HMO PERFORMANCE FORMULARY
Deductible then: $10/$25/$45 Mail Order $20/$50/$135	Deductible then: $10/$30/$60 Mail Order $20/$60/$180	$10/$30 Mail Order $25/$75

POS-PPO
$10/$20/$35 Mail Order $20/$40/$105 Out of Plan retail only Copay + 20%	$10/$25/$45 Mail Order $20/$50/$135 Out of Plan retail only Copay + 20%	$10/$30/$60 Mail Order $20/$60/$180 Out of Plan retail only Copay + 20%

Copayments for prescriptions filled at a Plan Pharmacy reflect up to a 30-day supply. Copayments for prescriptions filled through mail order reflect up to a 90-day supply of maintenance medication. Please Call Member Services or visit hne.com for a copy of the HNE Formulary.