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https://aptia365.com/atlanticunionbank 10 Copyright 2024 Aptia Insurance Services Group, LLC. All rights reserved.Co-Pay Plan ($1,000/$2,000) HSA Enhanced ($2,000/$4,000) HSA Basic ($4,000/$8,000)In-Network Out-ofNetwork In-Network Out-ofNetwork In-Network Out-ofNetworkRetail Prescriptions (30-day supply)Generic $15 copay* Not covered $15 copay Not covered $15 copay Not coveredPreferred Brand $40 copay* Not covered $40 copay Not covered $40 copay Not coveredNon-Preferred $75 copay* Not covered $75 copay Not covered $75 copay Not coveredSpecialty 20% (max $200)Not covered 20% (max $200)Not covered 20% (max $200)Not coveredMail-order Prescriptions (90-day supply)Generic $37.50 copay* Not covered $37.50 copay Not covered $37.50 copay Not coveredPreferred Brand $100 copay* Not covered $100 copay Not covered $100 copay Not coveredNon-Preferred $187.50 copay*Not covered $187.50 copay Not covered $187.50 copay Not coveredSpecialty Not available in 90 day suppliesNot available in 90 day suppliesNot available in 90 day supplies*Co-pays begin on effective date for the Co-Pay Plan ($1,000/$2,000) (prior to meeting annual deductible).Prescription Drug CoverageAnthemNetwork: PPOYour prescription drug coverage depends on the medical plan you choose. Medications are grouped into tiers, which determine your portion of the drug cost.. Drug co-pays apply to the following plans: Co-Pay plan ($1,000/$2,000) %u00b0 Applies to all prescription drugs before annual deductibleHSA Enhanced ($2,000/$4,000) and HSA Basic ($4,000/$8,000)%u00b0 Applies to Preventive Drugs before annual deductible%u00b0 Applies to Preventive and Non-Preventive Drugs after annual deductibleYou Pay What%u2019s CoveredLowest Cost Sharing Most Generic Prescription DrugsGeneric drugs that are equivalent to a brand product in dosage form, strength, quality aSecond-Lowest Cost SharingPreferred Brand Name DrugsDrugs sold under specific trade names that are favorably priced by the pharmacy plan.Higher Cost Sharing Non-Preferred Brand Name DrugsDrugs sold under specific trade names that have a more cost-effective alternative.Highest Cost SharingSpecialty DrugsSpecialty medications treat rare or complex conditions and are typically higher cost medications. Most will require pre-authorization before your plan will help pay for them, and some may require you to fill the prescription at a specialty pharmacy.Prescription Drug Coverage