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PLAN COMPARISONS

Compare our Plans

Summary of Benefits

Pharmacy Riders

We've Renamed Our Plans

Group Size:
Eligible Employees

1-5

6-50

51+

for Members

for Providers

for Employers

for Brokers

Pharmacy Riders

PRESCRIPTION DRUGS

(Listed as Generic/Formulary/Non-Formulary Drugs)

NOTE: If you already have a rate proposal, the rate is based on the Pharmacy
Rider you chose when the rate was generated.
Please check your rate proposal for the correct Pharmacy Rider.

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 Wise^Plus and HNE Wise^Max.		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 $20/$60

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.

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