2021
2022

Rx Premier – S7126

Premium: $24.90

Deductible: $0 (Tiers 1-2), $445 (Tiers 3-5)


Summary of Benefits

Evidence of Coverage

Rx Premier Formulary

Rx Plus – S7126

Premium: $91.90

Deductible: $445 (All tiers)


Summary of Benefits

Evidence of Coverage

Rx Plus Formulary

Rx Premier – S7126

Premium: $31.40

Deductible: $0 (Tiers 1-2), $480 (Tiers 3-5)

Summary of Benefits

Evidence of Coverage

Rx Premier Formulary

Rx Plus – S7126

Premium: $99.90

Deductible: $480 (All tiers)

Summary of Benefits

Evidence of Coverage

Rx Plus Formulary