RxSearch

About This Data

The information provided in the CA Internet Formulary reference is provided by Managed Markets Insight & Technology, LLC (“MMIT”). MMIT provides similar information in its CA Managed Care Formulary guide to practicing physicians in California.

The data contained in the CalChoice Internet Formulary Reference is provided by the health care organizations that are included behind the Listing of Plans menu item. The Site provides the formulary status for more than 600 pharmaceutical products. The fact that a drug is not included in this site does not necessarily mean that it is not on a particular managed care formulary. MMIT assembles the data into a standardized data set contained as a subset of the MMIT Formulary database, a national database of formularies for over 1100 managed care organizations. Once standardized, the information is accumulated and published in books or web sites such as this.

MMIT specializes in collecting and interpreting formulary information for the health care industry. MMIT employs professional pharmacists to manage the formulary data interpretation and data entry processes. The data provided here is regularly updated as changes are received from the CA health care organizations. The information is valid through the dates shown under the valid date column.

Public Domain Data Copyright

Formulary information is classified as public domain information. It cannot be owned by any party including the health plans that provide it. It can be formatted in certain published formats and protected under US copyright law. The information on this web site consists of pre-existing facts. Some of the information contained in this database is also available on individual plan web sites. Some of the information contained in the MMIT database but not necessarily in this data set is obtained from such public sites.

All of the information provided here is selected and formatted by using MMIT's formatting and in such formats is protected under MMIT copyrights.

Plan Information

This is a list of organizations (HMO plan or medical group) that publishes the formulary appearing under their name. The member services phone number is presented for the user's convenience. Please refer to the Effective Date and Valid Date which explain these two columns.

Information Dates

Formularies are dynamic. They are continuously changing as new drugs are added and old drugs are deleted, as plans add or change benefits and when some plans are bought or merged into others. Also, drugs may remain in a formulary but change status from time to time.

MMIT receives notice from the plans at about the same time as physicians do. However, in an effort to maintain the best information, MMIT checks with the listed CA plans on a monthly basis to be sure we have the latest information. There is no fixed schedule to these changes! There may be several changes at one time or no changes for several months. The schedules provided here match the information given to your physicians by these Health Care organizations. MMIT cannot guarantee and does not warrant the accuracy or completeness of this formulary information.

Accuracy

It is our intention to provide data that is as accurate as possible. As there is no industry standard for Drug statuses, the information contained here is subject to interpretation. For instance, what one plan may call a preferred drug another may call Approved. MMIT strives to standardize the information to the following interpretation.

Status	Symbol(s)	Interpretation
Preferred		Preferred over all other drugs in the same therapeutic category.
Approved		Approved for reimbursement without any restrictions.
Prior Authorization		Reimbursement will be allowed only when the claim has been submitted to plan officials by a prescriber for review prior to the issuance of a prescription.
Non-Formulary		The Plan lists this drug as not on the formulary. Please click on the icon to review the Plan's Benefits/Policies regarding non formulary drugs.
Not Reimbursed		This drug is not reimbursed by the plan.
Not Listed		No information available for this drug. It may or may not be reimbursable.
Benefits/Policies		Click the icon to view the Plan's Benefits/Policies.
Generic Available		The symbol indicates that the drug name it appears after is available as a generic equivalent. Health insurance providers almost always require that a generic be used if it is available.
Notes or Restrictions		Click the icon to view the Plan's notes or restrictions.

Frequently Asked Questions

What is a formulary?
What if my doctor wants to prescribe a non-formulary medication?
Why does my health plan have a formulary?
What is a generic drug? Is it safe to take it instead of the brand name drug?
How often is the information updated?
What is a therapeutic class and subclass?
What is a formulary status?
What is Prior Authorization?
How do I compare coverage for a drug between plans?
Does my doctor have these formularies?
What if my drug is not listed?
How can I find out if my drug is listed?
A drug I'm interested in is listed twice. What does that mean?
Are all unlisted drugs reimbursed if there isn't a not reimbursed symbol?
If my drug is not reimbursed, does that mean I cannot get it?

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What is a formulary?
A formulary is a list of prescription drugs that a health plan has approved for use by doctors. Health plans that have formularies develop their own unique list of "approved" drugs. Formularies may change at any time.

Health plans may only pay for medications that are on this "approved" list, unless your doctor goes through the health plan's Prior Authorization process.

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What if my doctor wants to prescribe a non-formulary medication?
Your doctor may prescribe a prescription drug that is not on your health plan's formulary; in that case you may have to pay the full price for the medication when you pick it up at the pharmacy.

Your doctor may be able to obtain "prior authorization" from the health plan to prescribe a non-formulary drug. This typically requires that your doctor contact the plan either in writing or on the telephone and make the case for a non-formulary drug. This process can be time consuming and if successful, you will have to obtain authorization every 30 days for refills.

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Why does my health plan have a formulary?
Health plans use formularies to control the cost of pharmaceutical health care. There are various approaches as to how plans will implement control. Some will use "closed" formularies that restrict which drugs a plan will pay for and which it will not. Others will use "open" formularies but include different co-pay levels. Others will use guidelines and protocols to encourage physicians to prescribe according to a predetermined therapeutic strategy developed by the plan's health professionals. And sometimes a formulary will include a mixture of these approaches.

Formularies differ between health plans and you should compare availability of medications before making a choice of health plan.

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What is a generic drug? Is it safe to take it instead of the brand name drug?
A generic drug is a copy of the original drug that is no longer protected by a U.S. patent. It is typically a drug that has been available for more than 10 years. Generic drug manufacturers are allowed to produce these drugs after the patent for the original has expired. Generic drugs are usually (not always) less expensive than brand drugs, since generic manufacturers haven't had to invest in the research and development of the drug when it was brought to market.

Substituting a generic drug for a brand-name drug usually has no adverse effect. For a few, there could be unintended side effects. If you find that you are having a problem with a generic drug, your doctor may switch your prescription to a branded drug at any time. Plans that recommend generic drugs almost always also cover brand name drugs that can be used for the same therapy. Check with your doctor before switching between brand name and generic drugs.

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How often is the information updated?
The information on this site is regularly updated to reflect the continuous changes in formularies. The frequency depends upon the number of changes being reported by the managed care organizations. That typically means three or four updates per year.

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What is a therapeutic class and subclass?
Therapeutic classes are used to categorize or group the drugs on the formulary. The classes group drugs which are considered similar by the disease they treat or by the effect they have on the body. Therapeutic subclasses further categorize the drugs into smaller groupings.

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What is a formulary status?
A formulary "status" is the means used by health plans to distinguish between drugs on the formulary. Your doctor uses these statuses to interpret the recommendations of the P&T Committee. InfoScan has developed a standardized set of statuses as used on this site to insure that the drugs are being classified using the same terminology for all plans. InfoScan's statuses are explained in the About This Data section of the main menu.

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What is Prior Authorization?
A health plan may give certain drugs a status of Prior Authorization (PAR)

. If your doctor wants to prescribe a PAR drug for you, he or she must follow the plan's procedure before the drug can be dispensed as a covered benefit. In most cases, the procedure includes filling out a request form which is then addressed by the P&T Committee or pharmacy staff responsible for evaluating requests. This process maybe time consuming and if successful, you may have to obtain authorization every 30 days for refills.

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How do I compare coverage for a drug between plans?
The easiest way to compare drug coverage between plans is to use the search menu. You can search by brand name or generic name. Click on the drug name. A list of all the plans in the database will appear and provide you with the status of your drug by plan. A key is available which explains the icons.

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Does my doctor have these formularies?
Yes. Your health plan sends it's affiliated doctors a copy of their plan formulary. InfoScan sometimes publishes plan formulary books. In California we also publish the Triple i CA Managed Care Formulary Guide which is sent free to approximately 24,000 California physicians. Also, this site can be used by doctors to review drug statuses.

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What if my drug is not listed?
There are a number of reasons the drug may have a "not listed" status. You will need to check with your plan for information about that drug or their policy for not listed drugs. You may sometimes find an explanation attached for a not listed drug by clicking on the note icon, if one is located next to the

symbol.

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How can I find out if my drug is listed?
From the search menu, on the letter of the alphabet that corresponds to the first letter of the drug you are seeking. This will give you a list of drug names to pick from. Scan the list and click the one you are interested in reviewing. The table will display the drug for all the plans in California.

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A drug I'm interested in is listed twice. What does that mean?
The drug is in two different therapeutic classes or subclasses. Your drug can be prescribed for more than one disease or condition. You will need to look at the appropriate therapeutic class for your condition to find the status. Statuses can differ between therapeutic classes. For instance, a drug can be preferred in one class and approved in another class.

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Are all unlisted drugs reimbursed if there isn't a not reimbursed symbol?
Not necessarily. You will need to check with your health plan to ensure they will reimburse you for a drug not on their formulary. In general, if the drug has a status of "approved" or "preferred", it will be reimbursed. If the drug has a status of "non-formulary" or "prior authorization", it may be reimbursed as usual, at a different rate or not at all.

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If my drug is not reimbursed, does that mean I cannot get it?
No. Doctors can prescribe any medication they choose. However, if the drug is not listed on the formulary and you cannot obtain it through the plan's prior authorization process, you may have to pay the total cost of the medication.

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Listing of Plans

EFFECTIVE 1/1/22 FOR NEW AND RENEWING GROUPS:

Plan Name	Member Services Number
Anthem Blue Cross HMO and PPO	(855) 383-7248
Cigna + Oscar	(855) 672-2789
Health Net	(800) 361-3366
Kaiser Permanente	(800) 464-4000
Sharp Health Plan	(800) 359-2002
Sutter Health Plus	(855) 315-5800
UnitedHealthcare	(800) 624-8822
Western Health Advantage	(888) 563-2250

EFFECTIVE 7/1/21 FOR NEW AND RENEWING GROUPS:

Plan Name	Member Services Number
Anthem Blue Cross HMO and PPO	(855) 383-7248
Cigna + Oscar	(855) 672-2789
Health Net	(800) 361-3366
Kaiser Permanente	(800) 464-4000
Oscar	(855) 672-2755
Sharp Health Plan	(800) 359-2002
Sutter Health Plus	(855) 315-5800
UnitedHealthcare	(800) 624-8822
Western Health Advantage	(888) 563-2250

EFFECTIVE 1/1/21 FOR NEW AND RENEWING GROUPS:

Plan Name	Member Services Number
Anthem Blue Cross HMO and PPO	(855) 383-7248
Health Net	(800) 361-3366
Kaiser Permanente	(800) 464-4000
Oscar	(855) 672-2755
Sharp Health Plan	(800) 359-2002
Sutter Health Plus	(855) 315-5800
UnitedHealthcare	(800) 624-8822
Western Health Advantage	(888) 563-2250

Effective 7/1/22

Platinum Tier HMO Rx Benefits

Participating Health Plan	Generic	Brand	Non- Formulary	Brand Deductible
Anthem Blue Cross HMO A	Level 1 $5 Copay/ Level 2 $10 Copay¹	Level 1 $20 Copay/ Level 2 $30 Copay¹	Level 1 $50 Copay/ Level 2 $60 Copay¹	N/A
Health Net HMO C	$5 Copay^2,3	$30 Copay^2,3	$50 Copay^2,3	N/A
Health Net HMO D	$5 Copay^2,3	$30 Copay^2,3	$50 Copay^2,3	N/A
Health Net HMO E	$5 Copay^2,3	$30 Copay^2,3	$50 Copay^2,3	N/A
Health Net HMO F	100% ^2,3	$30 Copay^2,3	$50 Copay^2,3	N/A
Health Net HMO G	100% ^2,3	$30 Copay^2,3	$50 Copay^2,3	N/A
Health Net HMO H	100% ^2,3	$30 Copay^2,3	$50 Copay^2,3	N/A
Kaiser Permanente HMO A	$5 Copay	$15 Copay	$15 Copay (with physician approval)	N/A
Kaiser Permanente HMO B	$5 Copay	$20 Copay	$20 Copay (with physician approval)	N/A
Sharp HMO A	$10 Copay	$25 Copay	$50 Copay	N/A
Sharp HMO B	$10 Copay	$25 Copay	$50 Copay	N/A
Sharp HMO C	$10 Copay	$25 Copay	$50 Copay	N/A
Sutter Health Plus HMO A	$5 Copay¹³	$20 Copay^8,9	$30 Copay^8,9	N/A
Sutter Health Plus HMO B	$5 Copay¹³	$15 Copay^8,9	$30 Copay^8,9	N/A
UnitedHealthcare HMO A	Tier 1 Non-specialty $5 Copay / Tier 1 Specialty $5 Copay⁷	Tier 2 Non-specialty $40 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $80 Copay / Tier 3 Specialty $250 Copay⁷	N/A
UnitedHealthcare HMO C	Tier 1 Non-specialty $5 Copay / Tier 1 Specialty $5 Copay⁷	Tier 2 Non-specialty $40 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $80 Copay / Tier 3 Specialty $250 Copay⁷	N/A
UnitedHealthcare HMO E	Tier 1 Non-specialty $5 Copay / Tier 1 Specialty $5 Copay⁷	Tier 2 Non-specialty $40 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $80 Copay / Tier 3 Specialty $250 Copay⁷	N/A
UnitedHealthcare HMO G	Tier 1 Non-specialty $5 Copay / Tier 1 Specialty $5 Copay⁷	Tier 2 Non-specialty $40 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $80 Copay / Tier 3 Specialty $250 Copay⁷	N/A
UnitedHealthcare HMO H	Tier 1 Non-specialty $5 Copay / Tier 1 Specialty $5 Copay⁷	Tier 2 Non-specialty $40 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $80 Copay / Tier 3 Specialty $250 Copay⁷	N/A
UnitedHealthcare HMO I	Tier 1 Non-specialty $5 Copay / Tier 1 Specialty $5 Copay⁷	Tier 2 Non-specialty $40 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $80 Copay / Tier 3 Specialty $250 Copay⁷	N/A
UnitedHealthcare HMO J	Tier 1 Non-specialty $5 Copay / Tier 1 Specialty $5 Copay⁷	Tier 2 Non-specialty $40 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $80 Copay / Tier 3 Specialty $250 Copay⁷	N/A
UnitedHealthcare HMO K	Tier 1 Non-specialty $5 Copay / Tier 1 Specialty $5 Copay⁷	Tier 2 Non-specialty $40 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $80 Copay / Tier 3 Specialty $250 Copay⁷	N/A
UnitedHealthcare HMO L	Tier 1 Non-specialty $5 Copay / Tier 1 Specialty $5 Copay⁷	Tier 2 Non-specialty $40 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $80 Copay / Tier 3 Specialty $250 Copay⁷	N/A
Western Health Advantage HMO A	$10 Copay	$30 Copay¹²	$50 Copay¹²	N/A
Western Health Advantage HMO B	$5 Copay	$20 Copay¹²	$30 Copay¹²	N/A
Western Health Advantage HMO C	$5 Copay	$30 Copay¹²	$50 Copay¹²	N/A

Platinum Tier HMO Mail Order Rx Benefits

90 Day Supply:

Participating Health Plan	Generic	Brand	Non- Formulary	Brand Deductible
Anthem Blue Cross HMO A	Level 1 $13 Copay¹	Level 1 $60 Copay¹	Level 1 $150 Copay¹	N/A
Health Net HMO C	$10 Copay^2,3	$75 Copay^2,3	$125 Copay^2,3	N/A
Health Net HMO D	$10 Copay^2,3	$75 Copay^2,3	$125 Copay^2,3	N/A
Health Net HMO E	$10 Copay^2,3	$75 Copay^2,3	$125 Copay^2,3	N/A
Health Net HMO F	100% ^2,3	$75 Copay^2,3	$125 Copay^2,3	N/A
Health Net HMO G	100% ^2,3	$75 Copay^2,3	$125 Copay^2,3	N/A
Health Net HMO H	100% ^2,3	$75 Copay^2,3	$125 Copay^2,3	N/A
Kaiser Permanente HMO A	$10 Copay	$40 Copay	$40 Copay (with physician Approval)	N/A
Kaiser Permanente HMO B	$10 Copay	$30 Copay	$30 Copay (with physician approval)	N/A
Sharp HMO A	$20 Copay	$50 Copay	$100 Copay	N/A
Sharp HMO B	$20 Copay	$50 Copay	$100 Copay	N/A
Sharp HMO C	$20 Copay	$50 Copay	$100 Copay	N/A
Sutter Health Plus HMO A	$10 Copay¹³	$40 Copay^8,9	$60 Copay^8,9	N/A
Sutter Health Plus HMO B	$10 Copay¹³	$30 Copay^8,9	$60 Copay^8,9	N/A
UnitedHealthcare HMO A	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay⁷	Tier 2 Non-specialty $80 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $160 Copay / Tier 3 Specialty $500 Copay⁷	N/A
UnitedHealthcare HMO C	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay⁷	Tier 2 Non-specialty $80 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $160 Copay / Tier 3 Specialty $500 Copay⁷	N/A
UnitedHealthcare HMO E	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay⁷	Tier 2 Non-specialty $80 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $160 Copay / Tier 3 Specialty $500 Copay⁷	N/A
UnitedHealthcare HMO G	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay⁷	Tier 2 Non-specialty $80 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $160 Copay / Tier 3 Specialty $500 Copay⁷	N/A
UnitedHealthcare HMO H	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay⁷	Tier 2 Non-specialty $80 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $160 Copay / Tier 3 Specialty $500 Copay⁷	N/A
UnitedHealthcare HMO I	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay⁷	Tier 2 Non-specialty $80 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $160 Copay / Tier 3 Specialty $500 Copay⁷	N/A
UnitedHealthcare HMO J	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay⁷	Tier 2 Non-specialty $80 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $160 Copay / Tier 3 Specialty $500 Copay⁷	N/A
UnitedHealthcare HMO K	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay⁷	Tier 2 Non-specialty $80 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $160 Copay / Tier 3 Specialty $500 Copay⁷	N/A
UnitedHealthcare HMO L	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay⁷	Tier 2 Non-specialty $80 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $160 Copay / Tier 3 Specialty $500 Copay⁷	N/A
Western Health Advantage HMO A	$25 Copay	$75 Copay¹²	$125 Copay¹²	N/A
Western Health Advantage HMO B	$13 Copay	$50 Copay¹²	$75 Copay¹²	N/A
Western Health Advantage HMO C	$13 Copay	$75 Copay¹²	$125 Copay¹²	N/A

Platinum Tier PPO/EPO Rx Benefits

Participating Health Plan	Generic		Brand		Non-Formulary		Brand Deductible
	Participating Pharmacy	Non-Participating Pharmacy	Participating Pharmacy	Non-Participating Pharmacy	Participating Pharmacy	Non-Participating Pharmacy	Participating Pharmacy	Non-Participating Pharmacy
Cigna + Oscar EPO C	$5 Copay	Not Covered	$30 Copay	Not Covered	$50 Copay	Not Covered	N/A	N/A
Cigna + Oscar EPO D	$5 Copay (overall ded waived)	Not Covered	$30 Copay (overall ded waived)	Not Covered	$50 Copay (overall ded waived)	Not Covered	N/A	N/A
Cigna + Oscar EPO E	$10 Copay (overall ded waived)	Not Covered	$35 Copay (overall ded waived)	Not Covered	$75 Copay (overall ded waived)	Not Covered	N/A	N/A

Platinum Tier PPO/EPO Mail Order Rx Benefits

90 Day Supply:

Participating Health Plan	Generic	Brand	Non- Formulary	Brand Deductible
Cigna + Oscar EPO C	$15 Copay	$90 Copay	$150 Copay	N/A
Cigna + Oscar EPO D	$15 Copay (overall ded waived)	$90 Copay (overall ded waived)	$150 Copay (overall ded waived)	N/A
Cigna + Oscar EPO E	$30 Copay (overall ded waived)	$105 Copay (overall ded waived)	$225 Copay (overall ded waived)	N/A

Gold Tier HMO Rx Benefits

Participating Health Plan	Generic	Brand	Non- Formulary	Brand Deductible
Anthem Blue Cross HMO A	Level 1 $10 Copay/ Level 2 $20 Copay¹	Level 1 $50 Copay/ Level 2 $60 Copay¹	Level 1 $90 Copay/ Level 2 $100 Copay¹	N/A
Anthem Blue Cross HMO B	Level 1 $10 Copay/ Level 2 $20 Copay¹	Level 1 $50 Copay/ Level 2 $60 Copay¹	Level 1 $90 Copay/ Level 2 $100 Copay¹	N/A
Anthem Blue Cross HMO C	Level 1 $10 Copay/ Level 2 $20 Copay¹	Level 1 $50 Copay/ Level 2 $60 Copay¹	Level 1 $90 Copay/ Level 2 $100 Copay¹	N/A
Health Net HMO A	$15 Copay^2,3	$50 Copay^2,3	$70 Copay^2,3	N/A
Health Net HMO B	$15 Copay^2,3	$50 Copay^2,3	$70 Copay^2,3	N/A
Health Net HMO C	$15 Copay^2,3	$50 Copay^2,3	$70 Copay^2,3	N/A
Health Net HMO D	$15 Copay^2,3	$50 Copay^2,3	$70 Copay^2,3	N/A
Health Net HMO E	$15 Copay^2,3	$50 Copay^2,3	$70 Copay^2,3	N/A
Health Net HMO F	$15 Copay^2,3	$50 Copay^2,3	$70 Copay^2,3	N/A
Health Net HMO G	$15 Copay^2,3	$50 Copay^2,3	$70 Copay^2,3	N/A
Kaiser Permanente HMO B	$15 Copay (overall ded waived)	$40 Copay (overall ded waived)	$40 Copay (overall ded waived; with physician approval)	N/A
Kaiser Permanente HMO C	$15 Copay	$40 Copay	$40 Copay ( with physician approval)	N/A
Kaiser Permanente HMO D	$20 Copay (ded waived)	$50 Copay	$50 Copay ( with physician approval)	$250/$500
Kaiser Permanente HMO E*	$15 Copay	$45 Copay	$45 Copay ( with physician approval)	Combined Med/Rx ded
Sharp HMO A	$16 Copay (ded waived)	$35 Copay	$70 Copay	$200/$400
Sharp HMO B	$16 Copay (ded waived)	$40 Copay	$75 Copay	$400/$800
Sharp HMO D	$16 Copay	$35 Copay	$70 Copay	N/A
Sutter Health Plus HMO A	$5 Copay (overall ded waived)¹³	$15 Copay (overall ded waived)^8,9	$30 Copay (overall ded waived)^8,9	N/A
Sutter Health Plus HMO B	$15 Copay (overall ded waived)¹³	$40 Copay (overall ded waived)^8,9	$70 Copay (overall ded waived)^8,9	N/A
UnitedHealthcare HMO A	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay (ded waived)⁷	Tier 2 Non-specialty $50 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $100 Copay / Tier 3 Specialty $250 Copay⁷	$250/$500
UnitedHealthcare HMO B	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay (ded waived)⁷	Tier 2 Non-specialty $50 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $100 Copay / Tier 3 Specialty $250 Copay⁷	$250/$500
UnitedHealthcare HMO F	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay (ded waived)⁷	Tier 2 Non-specialty $50 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $100 Copay / Tier 3 Specialty $250 Copay⁷	$100/$200
UnitedHealthcare HMO G	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay (ded waived)⁷	Tier 2 Non-specialty $50 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $100 Copay / Tier 3 Specialty $250 Copay⁷	$100/$200
UnitedHealthcare HMO H	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay (ded waived)⁷	Tier 2 Non-specialty $50 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $100 Copay / Tier 3 Specialty $250 Copay⁷	$250/$500
UnitedHealthcare HMO J	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay (ded waived)⁷	Tier 2 Non-specialty $50 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $100 Copay / Tier 3 Specialty $250 Copay⁷	$250/$500
UnitedHealthcare HMO L	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay (ded waived)⁷	Tier 2 Non-specialty $50 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $100 Copay / Tier 3 Specialty $250 Copay⁷	$250/$500
UnitedHealthcare HMO M	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay (ded waived)⁷	Tier 2 Non-specialty $50 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $100 Copay / Tier 3 Specialty $250 Copay⁷	$100/$200
UnitedHealthcare HMO N	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay (ded waived)⁷	Tier 2 Non-specialty $50 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $100 Copay / Tier 3 Specialty $250 Copay⁷	$250/$500
UnitedHealthcare HMO O	Tier 1 Non-specialty $5 Copay / Tier 1 Specialty $5 Copay (ded waived)⁷	Tier 2 Non-specialty $50 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $100 Copay / Tier 3 Specialty $250 Copay⁷	$250/$500
UnitedHealthcare HMO P	Tier 1 Non-specialty $5 Copay / Tier 1 Specialty $5 Copay (ded waived)⁷	Tier 2 Non-specialty $50 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $100 Copay / Tier 3 Specialty $250 Copay⁷	$250/$500
UnitedHealthcare HMO Q	Tier 1 Non-specialty $5 Copay / Tier 1 Specialty $5 Copay (ded waived)⁷	Tier 2 Non-specialty $50 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $100 Copay / Tier 3 Specialty $250 Copay⁷	$250/$500
Western Health Advantage HMO A	$20 Copay	$50 Copay ¹²	$75 Copay¹²	N/A
Western Health Advantage HMO B	$15 Copay (overall ded waived)	$40 Copay (overall ded waived)¹²	$70 Copay (overall ded waived)¹²	N/A
Western Health Advantage HMO C	$10 Copay (ded waived)	$50 Copay ^5,12	$75 Copay^5,12	$500/$1,000
Western Health Advantage HMO D*	100%⁵	$30 Copay^5,12	$50 Copay^5,12	Combined Med/Rx ded

Gold Tier HMO Mail Order Rx Benefits

90 Day Supply:

Participating Health Plan	Generic	Brand	Non- Formulary	Brand Deductible
Anthem Blue Cross HMO A	Level 1 $25 Copay¹	Level 1 $150 Copay¹	Level 1 $270 Copay¹	N/A
Anthem Blue Cross HMO B	Level 1 $25 Copay¹	Level 1 $150 Copay¹	Level 1 $270 Copay¹	N/A
Anthem Blue Cross HMO C	Level 1 $25 Copay¹	Level 1 $150 Copay¹	Level 1 $270 Copay¹	N/A
Health Net HMO A	$30 Copay^2,3	$125 Copay^2,3	$175 Copay^2,3	N/A
Health Net HMO B	$30 Copay^2,3	$125 Copay^2,3	$175 Copay^2,3	N/A
Health Net HMO C	$30 Copay^2,3	$125 Copay^2,3	$175 Copay^2,3	N/A
Health Net HMO D	$30 Copay^2,3	$125 Copay^2,3	$175 Copay^2,3	N/A
Health Net HMO E	$30 Copay^2,3	$125 Copay^2,3	$175 Copay^2,3	N/A
Health Net HMO F	$30 Copay^2,3	$125 Copay^2,3	$175 Copay^2,3	N/A
Health Net HMO G	$30 Copay^2,3	$125 Copay^2,3	$175 Copay^2,3	N/A
Kaiser Permanente HMO B	$30 Copay (overall ded waived)	$80 Copay (overall ded waived)	$80 Copay (overall ded waived; with physician approval)	$250/$500
Kaiser Permanente HMO C	$30 Copay	$80 Copay	$80 Copay (with physician approval)	N/A
Kaiser Permanente HMO D	$40 Copay (ded waived)	$100 Copay	$100 Copay (with physician approval)	$250/$500
Kaiser Permanente HMO E*	$30 Copay	$90 Copay	$90 Copay (with physician approval)	Combined Med/Rx ded
Sharp HMO A	$32 Copay (ded waived)	$70 Copay	$140 Copay	$200/$400
Sharp HMO B	$32 Copay (ded waived)	$80 Copay	$150 Copay	$400/$800
Sharp HMO D	$32 Copay	$70 Copay	$140 Copay	N/A
Sutter Health Plus HMO A	$10 Copay (overall ded waived)¹³	$30 Copay (overall ded waived)^8,9	$60 Copay (overall ded waived)^8,9	N/A
Sutter Health Plus HMO B	$30 Copay (overall ded waived)¹³	$80 Copay (overall ded waived)^8,9	$140 Copay (overall ded waived)^8,9	N/A
UnitedHealthcare HMO A	Tier 1 Non-specialty $20 Copay / Tier 1 Specialty $20 Copay (ded waived)⁷	Tier 2 Non-specialty $100 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $200 Copay / Tier 3 Specialty $500 Copay⁷	$250/$500
UnitedHealthcare HMO B	Tier 1 Non-specialty $20 Copay / Tier 1 Specialty $20 Copay (ded waived)⁷	Tier 2 Non-specialty $100 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $200 Copay / Tier 3 Specialty $500 Copay⁷	$250/$500
UnitedHealthcare HMO F	Tier 1 Non-specialty $20 Copay / Tier 1 Specialty $20 Copay (ded waived)⁷	Tier 2 Non-specialty $100 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $200 Copay / Tier 3 Specialty $500 Copay⁷	$100/$200
UnitedHealthcare HMO G	Tier 1 Non-specialty $20 Copay / Tier 1 Specialty $20 Copay (ded waived)⁷	Tier 2 Non-specialty $100 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $200 Copay / Tier 3 Specialty $500 Copay⁷	$100/$200
UnitedHealthcare HMO H	Tier 1 Non-specialty $20 Copay / Tier 1 Specialty $20 Copay (ded waived)⁷	Tier 2 Non-specialty $100 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $200 Copay / Tier 3 Specialty $500 Copay⁷	$250/$500
UnitedHealthcare HMO J	Tier 1 Non-specialty $20 Copay / Tier 1 Specialty $20 Copay (ded waived)⁷	Tier 2 Non-specialty $100 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $200 Copay / Tier 3 Specialty $500 Copay⁷	$250/$500
UnitedHealthcare HMO L	Tier 1 Non-specialty $20 Copay / Tier 1 Specialty $20 Copay (ded waived)⁷	Tier 2 Non-specialty $100 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $200 Copay / Tier 3 Specialty $500 Copay⁷	$250/$500
UnitedHealthcare HMO M	Tier 1 Non-specialty $20 Copay / Tier 1 Specialty $20 Copay (ded waived)⁷	Tier 2 Non-specialty $100 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $200 Copay / Tier 3 Specialty $500 Copay⁷	$100/$200
UnitedHealthcare HMO N	Tier 1 Non-specialty $20 Copay / Tier 1 Specialty $20 Copay (ded waived)⁷	Tier 2 Non-specialty $100 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $200 Copay / Tier 3 Specialty $500 Copay⁷	$250/$500
UnitedHealthcare HMO O	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay (ded waived)⁷	Tier 2 Non-specialty $100 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $200 Copay / Tier 3 Specialty $500 Copay⁷	$250/$500
UnitedHealthcare HMO P	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay (ded waived)⁷	Tier 2 Non-specialty $100 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $200 Copay / Tier 3 Specialty $500 Copay⁷	$250/$500
UnitedHealthcare HMO Q	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay (ded waived)⁷	Tier 2 Non-specialty $100 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $200 Copay / Tier 3 Specialty $500 Copay⁷	$250/$500
Western Health Advantage HMO A	$50 Copay	$125 Copay¹²	$188 Copay¹²	N/A
Western Health Advantage HMO B	$38 Copay (overall ded waived)	$100 Copay (overall ded waived)^5,12	$175 Copay (overall ded waived)^5,12	N/A
Western Health Advantage HMO C	$25 Copay (ded waived)	$125 Copay^5,12	$188 Copay^5,12	$500/$1,000
Western Health Advantage HMO D*	100%⁵	$75 Copay^5,12	$125 Copay^5,12	Combined Med/Rx ded

Gold Tier PPO/EPO Rx Benefits

Participating Health Plan	Generic		Brand		Non-Formulary		Brand Deductible
	Participating Pharmacy	Non-Participating Pharmacy	Participating Pharmacy	Non-Participating Pharmacy	Participating Pharmacy	Non-Participating Pharmacy	Participating Pharmacy	Non-Participating Pharmacy
Anthem Blue Cross PPO A	Level 1 $10 Copay/ Level 2 $20 Copay (ded waived)¹	Not Covered	Level 1 $50 Copay/ Level 2 $60 Copay¹	Not Covered	Level 1 $90 Copay/ Level 2 $100 Copay¹	Not Covered	$250/$500	N/A
Anthem Blue Cross PPO B	Level 1 $10 Copay/ Level 2 $20 Copay (ded waived)¹	Not Covered	Level 1 $50 Coapy/ Level 2 $60 Copay¹	Not Covered	Level 1 $90 Copay/ Level 2 $100 Copay¹	Not Covered	$250/$500	N/A
Anthem Blue Cross PPO C	Level 1 $10 Copay/ Level 2 $20 Copay (ded waived)¹	Not Covered	Level 1 $50 Copay/ Level 2 $60 Copay¹	Not Covered	Level 1 $90 Copay/ Level 2 $100 Copay¹	Not Covered	$150/$300	N/A
Anthem Blue Cross PPO D	Level 1 $10 Copay/ Level 2 $20 Copay (ded waived)¹	Not Covered	Level 1 $50 Copay/ Level 2 $60 Copay¹	Not Covered	Level 1 $90 Copay/ Level 2 $100 Copay¹	Not Covered	$250/$500	N/A
Anthem Blue Cross PPO E	Level 1 $10 Copay/ Level 2 $20 Copay (ded waived)¹	Not Covered	Level 1 $50 Copay/ Level 2 $60 Copay¹	Not Covered	Level 1 $90 Copay/ Level 2 $100 Copay¹	Not Covered	$150/$300	N/A
Cigna + Oscar EPO C	$15 Copay	Not Covered	$40 Copay	Not Covered	$90 Copay	Not Covered	N/A	N/A
Cigna + Oscar EPO D	$15 Copay (ded waived)	Not Covered	$45 Copay	Not Covered	$90 Copay	Not Covered	$300/$600	N/A
Cigna + Oscar EPO E	$15 Copay (ded waived)	Not Covered	$45 Copay	Not Covered	$90 Copay	Not Covered	$300/$600	N/A

Gold Tier PPO/EPO Mail Order Rx Benefits

90 Day Supply:

Participating Health Plan	Generic	Brand	Non- Formulary	Brand Deductible
Anthem Blue Cross PPO A	Level 1 $25 Copay(ded waived)¹	Level 1 $150 Copay¹	Level 1 $270 Copay¹	$250/$500
Anthem Blue Cross PPO B	Level 1 $25 Copay(ded waived)¹	Level 1 $150 Copay¹	Level 1 $270 Copay¹	$250/$500
Anthem Blue Cross PPO C	Level 1 $25 Copay(ded waived)¹	Level 1 $150 Copay¹	Level 1 $270 Copay¹	$150/$300
Anthem Blue Cross PPO D	Level 1 $25 Copay (ded waived)¹	Level 1 $150 Copay¹	Level 1 $270 Copay¹	$250/$500
Anthem Blue Cross PPO E	Level 1 $25 Copay (ded waived)¹	Level 1 $150 Copay¹	Level 1 $270 Copay¹	$150/$300
Cigna + Oscar EPO C	$45 Copay	$120 Copay	$270 Copay	N/A
Cigna + Oscar EPO D	$45 Copay(ded waived)	$135 Copay	$270 Copay	$300/$600
Cigna + Oscar EPO E	$45 Copay (ded waived)	$135 Copay	$270 Copay	$300/$600

Silver Tier HMO Rx Benefits

Participating Health Plan	Generic	Brand	Non- Formulary	Brand Deductible
Anthem Blue Cross HMO A	Level 1 $15 Copay/ Level 2 $20 Copay (ded waived)¹	Level 1 $70 Copay/ Level 2 $80 Copay¹	Level 1 $110 Copay/ Level 2 $120 Copay¹	$300/$600
Anthem Blue Cross HMO B	Level 1 $15 Copay/ Level 2 $20 Copay (ded waived)¹	Level 1 $70 Copay/ Level 2 $80 Copay¹	Level 1 $110 Copay/ Level 2 $120 Copay¹	$300/$600
Anthem Blue Cross HMO C	Level 1 $15 Copay/ Level 2 $20 Copay (ded waived)¹	Level 1 $70 Copay/ Level 2 $80 Copay¹	Level 1 $110 Copay/ Level 2 $120 Copay¹	$300/$600
Health Net HMO A	$20 Copay^2,3	$50% (up to $250 per prescription¹¹)^2,3	50% (up to $250 per prescription¹¹)^2,3	$750/$1,500
Health Net HMO C	$15 Copay (ded waived)^2,3	60% (up to $250 per prescription¹¹)^2,3	60% (up to $250 per prescription¹¹)^2,3	$250/$500
Kaiser Permanente HMO A	$20 Copay (ded waived)	$75 Copay	$75 Copay (with physician approval)	$500/$1,000
Kaiser Permanente HMO B	$20 Copay (ded waived)	$75 Copay	$75 Copay (with physician approval)	$350/$700
Kaiser Permanente HMO C	$17 Copay (ded waived)	$80 Copay	$80 Copay (with physician approval)	$300/$600
Kaiser Permanente HMO D*	80% (up to $250 per prescription¹¹)	80% (up to $250 per prescription¹¹)	80% (up to $250 per prescription¹¹)(with physician approval)	Combined Med/Rx ded
Kaiser Permanente HMO E	$20 Copay (ded waived)	$75 Copay	$75 Copay (with physician approval)	Combined Med/Rx ded
Sharp HMO A	$16 Copay (ded waived)	$105 Copay	$135 Copay	$250/$500
Sharp HMO B	$16 Copay (ded waived)	$100 Copay	$160 Copay	$250/$500
Sharp HMO C	$160 Copay (overall ded waived)	$100 Copay (overall ded waived)	$150 Copay (overall ded waived)	N/A
Sutter Health Plus HMO B	$17 Copay (ded waived)¹³	$80 Copay^8,9	$110 Copay^8,9	$300/$600
Sutter Health Plus HMO C*	$10 Copay¹³	$20 Copay^8,9	$40 Copay^8,9	Combined Med/ Rx ded
UnitedHealthcare HMO A	Tier 1 Non-specialty $20 Copay / Tier 1 Specialty $20 Copay (ded waived)⁷	Tier 2 Non-specialty $80 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $125 Copay / Tier 3 Specialty $250 Copay⁷	$400/$800
UnitedHealthcare HMO E	Tier 1 Non-specialty $20 Copay / Tier 1 Specialty $20 Copay (ded waived)⁷	Tier 2 Non-specialty $80 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $125 Copay / Tier 3 Specialty $250 Copay⁷	$400/$800
UnitedHealthcare HMO F	Tier 1 Non-specialty $20 Copay / Tier 1 Specialty $20 Copay (ded waived)⁷	Tier 2 Non-specialty $80 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $125 Copay / Tier 3 Specialty $250 Copay⁷	$400/$800
UnitedHealthcare HMO G	Tier 1 Non-specialty $15 Copay / Tier 1 Specialty $15 Copay (ded waived)⁷	Tier 2 Non-specialty $75 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $125 Copay / Tier 3 Specialty $250 Copay⁷	$400/$800
Western Health Advantage HMO A	$15 Copay (ded waived)	$55 Copay^5,12	$85 Copay^5,12	$250/$500
Western Health Advantage HMO B	$17 Copay (ded waived)	$80 Copay^5,12	$110 Copay^5,12	$300/$600
Western Health Advantage HMO C*	80% (up to $250 per 30 day supply¹¹)^5,6	80% (up to $250 per 30 day supply¹¹)^5,6,12	80% (up to $250 per 30 day supply¹¹)^5,6,12	Combined Med/Rx ded

Silver Tier HMO Mail Order Rx Benefits

90 Day Supply:

Participating Health Plan	Generic	Brand	Non- Formulary	Brand Deductible
Anthem Blue Cross HMO A	Level 1 $38 Copay (ded waived)¹	Level 1 $210 Copay¹	Level 1 $330 Copay¹	$300/$600
Anthem Blue Cross HMO B	Level 1 $38 Copay (ded waived)¹	Level 1 $210 Copay¹	Level 1 $330 Copay¹	$300/$600
Anthem Blue Cross HMO C	Level 1 $38 Copay (ded waived)¹	Level 1 $210 Copay¹	Level 1 $330 Copay¹	$300/$600
Health Net HMO A	$40 Copay^2,3	50% (up to $750 per prescription¹¹)^2,3	50% (up to $750 per prescription¹¹)^2,3	$750/$1,500
Health Net HMO C	$30 Copay (ded waived)^2,3	60% (up to $750 per prescription¹¹)^2,3	60% (up to $750 per prescription¹¹)^2,3	$250/$500
Kaiser Permanente HMO A	$40 Copay (ded waived)	$150 Copay	$150 Copay (with physician approval)	$500/$1,000
Kaiser Permanente HMO B	$40 Copay (ded waived)	$150 Copay	$150 Copay (with physician approval)	$350/$700
Kaiser Permanente HMO C	$34 Copay (ded waived)	$160 Copay	$160 Copay (with physician approval)	$500/$1,000
Kaiser Permanente HMO D*	80% (up to $500 per prescription¹¹)	80% (up to $500 per prescription¹¹)	80% (up to $500 per prescription¹¹) (with physician approval)	Combined Med/Rx ded
Kaiser Permanente HMO E	$40 Copay (ded waived)	$150 Copay	$150 Copay (with physician approval)	Combined Med/Rx ded
Sharp HMO A	$32 Copay (ded waived)	$210 Copay	$270 Copay	$250/$500
Sharp HMO B	$32 Copay (ded waived)	$200 Copay	$320 Copay	$250/$500
Sharp HMO C	$32 Copay (overall ded waived)	$200 Copay	$300 Copay	N/A
Sutter Health Plus HMO B	$34 Copay (ded waived)¹³	$160 Copay^8,9	$220 Copay^8,9	$300/$600
Sutter Health Plus HMO C*	$20 Copay¹³	$40 Copay^8,9	$80 Copay^8,9	Combined Med/Rx ded
UnitedHealthcare HMO A	Tier 1 Non-specialty $40 Copay / Tier 1 Specialty $40 Copay (ded waived)⁷	Tier 2 Non-specialty $160 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $250 Copay / Tier 3 Specialty $500 Copay⁷	$400/$800
UnitedHealthcare HMO E	Tier 1 Non-specialty $40 Copay / Tier 1 Specialty $40 Copay (ded waived)⁷	Tier 2 Non-specialty $160 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $250 Copay / Tier 3 Specialty $500 Copay⁷	$400/$800
UnitedHealthcare HMO F	Tier 1 Non-specialty $40 Copay / Tier 1 Specialty $40 Copay (ded waived)⁷	Tier 2 Non-specialty $160 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $250 Copay / Tier 3 Specialty $500 Copay⁷	$400/$800
UnitedHealthcare HMO G	Tier 1 Non-specialty $30 Copay / Tier 1 Specialty $30 Copay (ded waived)⁷	Tier 2 Non-specialty $150 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $250 Copay / Tier 3 Specialty $500 Copay⁷	$400/$800
Western Health Advantage HMO A	$38 Copay (ded waived)	$138 Copay^5,12	$213 Copay^5,12	$250/$500
Western Health Advantage HMO B	$43 Copay (ded waived)	$200 Copay^5,12	$275 Copay^5,12	$300/$600
Western Health Advantage HMO C*	80% (up to $625 per prescription¹¹)^5,6	80% (up to $625 per prescription¹¹)^5,6,12	80% (up to $625 per prescription¹¹)^5,6,12	Combined Med/Rx ded

Silver Tier PPO/EPO Rx Benefits

Participating Health Plan	Generic		Brand		Non-Formulary		Brand Deductible
	Participating Pharmacy	Non-Participating Pharmacy	Participating Pharmacy	Non-Participating Pharmacy	Participating Pharmacy	Non-Participating Pharmacy	Participating Pharmacy	Non-Participating Pharmacy
Anthem Blue Cross PPO A	Level 1 $15 Copay/ Level 2 $20 Copay (ded waived)¹	Not Covered	Level 1 $70 Copay/ Level 2 $80 Copay¹	Not Covered	Level 1 $110 Copay/ Level 2 $120 Copay¹	Not Covered	$300/$600	N/A
Anthem Blue Cross PPO B	Level 1 $15 Copay/ Level 2 $20 Copay (ded waived)¹	Not Covered	Level 1 $70 Copay/ Level 2 $80 Copay¹	Not Covered	Level 1 $110 Copay/ Level 2 $120 Copay¹	Not Covered	$300/$600	N/A
Anthem Blue Cross PPO C	Level 1 $15 Copay/ Level 2 $20 Copay (ded waived)¹	Not Covered	Level 1 $70 Copay/ Level 2 $80 Copay¹	Not Covered	Level 1 $110 Copay/ Level 2 $120 Copay¹	Not Covered	$300/$600	N/A
Anthem Blue Cross EPO A	Level 1 $15 Copay/ Level 2 $20 Copay (ded waived)^1,14	Not Covered	Level 1 $70 Copay/ Level 2 $80 Copay^1,14	Not Covered	Level 1 $110 Copay/ Level 2 $120 Copay¹	Not Covered	$300/$600	N/A
Anthem Blue Cross EPO B*	Level 1 $15 Copay / Level 2 $20 Copay)¹	Not Covered	Level 1 $70 Copay / Level 2 $80 Copay¹	Not Covered	Level 1 $110 Copay / Level 2 $120 Copay¹	Not Covered	Combined Med/Rx/Ped Dental ded	N/A
Cigna + Oscar EPO C	$25 Copay (ded waived)	Not Covered	$75 Copay	Not Covered	$125 Copay	Not Covered	$250/$500	N/A
Cigna + Oscar EPO D	$25 Copay(overall ded waived)	Not Covered	$75 Copay(overall ded waived)	Not Covered	$125 Copay(overall ded waived)	Not Covered	N/A	N/A
Cigna + Oscar EPO E*	$20 Copay	Not Covered	$60 Copay	Not Covered	$90 Copay	Not Covered	Combined Med/Rx/Ped Dental ded	N/A

Silver Tier PPO/EPO Mail Order Rx Benefits

90 Day Supply:

Participating Health Plan	Generic	Brand	Non- Formulary	Brand Deductible
Anthem Blue Cross PPO A	Level 1 $38 Copay(ded waived)¹	Level 1 $210 Copay¹	Level 1 $330 Copay¹	$300/$600
Anthem Blue Cross PPO B	Level 1 $38 Copay(ded waived)¹	Level 1 $210 Copay¹	Level 1 $330 Copay¹	$300/$600
Anthem Blue Cross PPO C	Level 1 $38 Copayded waived)¹	Level 1 $210 Copay¹	Level 1 $330 Copay¹	$300/$600
Anthem Blue Cross EPO A	Level 1 $38 Copay (ded waived)¹	Level 1 $210 Copay¹	Level 1 $330 Copay¹	$300/$600
Anthem Blue Cross EPO B*	Level 1 $38 Copay^1,14	Level 1 $210 Copay^1,14	Level 1 $330 Copay¹	Combined Med/Rx/Ped dental ded
Cigna + Oscar EPO C	$75 Copay(ded waived)	$225 Copay	$375 Copay	$250/$500
Cigna + Oscar EPO D	$75 Copay(overall ded waived)	$225 Copay(overall ded waived)	$375 Copay(overall ded waived)	N/A
Cigna + Oscar EPO E*	$60 Copay	$180 Copay	$270 Copay	Combined Med/Rx/Ped dental ded

Bronze Tier HMO Rx Benefits

Participating Health Plan	Generic	Brand	Non- Formulary	Brand Deductible
Health Net HMO A	$18 Copay^2,3	60% (up to $500 per prescription¹¹)^2,3	60% (up to $500 per prescription¹¹)^2,3	$500/$1,000
Kaiser Permanente HMO A	$18 Copay	60% (up to $500 per prescription¹¹)	60% (up to $500 per prescription¹¹;with physician approval)	$500/$1,000
Kaiser Permanente HMO B	$20 Copay (ded waived)	50% (up to $500 per prescription¹¹)	50% (up to $500 per prescription¹¹;with physician approval)	Combined Med/Rx ded
Kaiser Permanente HMO C*	100%	100%	100% (with physician approval)	Combined Med/Rx ded
Sharp HMO A	$16 Copay (overall ded waived)	$60 Copay (overall ded waived)	$100 Copay (overall ded waived)	N/A
Sharp HMO B	60% (up to $500 per prescription¹¹)	60% (up to $500 per prescription¹¹)	60% (up to $500 per prescription¹¹)	Combined Med/Rx ded
Sutter Health Plus HMO A	$18 Copy¹³	60% (up to $500 per prescription¹¹)^8,9	60% (up to $500 per prescription¹¹)^8,9	$500/$1,000
Sutter Health Plus HMO B*	100%¹³	100%^8,9	100%^8,9	Combined Med/Rx ded
Western Health Advantage HMO B	$18 Copay⁵	60% (up to $500 per prescription¹¹)^5,12	60% (up to $500 per prescription¹¹)^5,12	$500/$1,000
Western Health Advantage HMO C*	100%⁵	100%^5,12	100%^5,12	Combined Med/Rx ded

Bronze Tier HMO Mail Order Rx Benefits

90 Day Supply:

Participating Health Plan	Generic	Brand	Non- Formulary	Brand Deductible

Health Net HMO A	$36 Copay^2,3	60% (up to $1,500 per prescription¹¹)^2,3	50% (up to $1,500 per prescription¹¹)^2,3	$500/$1,000
Kaiser Permanente HMO A	$36 Copay	60% (up to $1,000 per prescription¹¹)	60% (up to $1,000 per prescription¹¹;with physician approval)	$500/$1,000
Kaiser Permanente HMO B	$40 Copay (ded waived)	50% (up to $1,000 per prescription¹¹)	50% (up to $1,000 per prescription¹¹;with physician approval)	Combined Med/Rx ded
Kaiser Permanente HMO C*	100%	100%	100% (with physician approval)	Combined Med/Rx ded
Sharp HMO A	$32 Copay (overall ded waived)	$120 Copay (overall ded waived)	$200 Copay (overall ded waived)	N/A
Sharp HMO B*	60% (up to $1,000 per prescription¹¹)	60% (up to $1,000 per prescription¹¹)	60% (up to $1,000 per prescription¹¹)	Combined Med/Rx ded
Sutter Health Plus HMO A	$36 Copay¹³	60% (up to $1,000 per prescription¹¹)^8,9	60% (up to $1,000 per prescription¹¹)^8,9	$500/$1,000
Sutter Health Plus HMO B*	100%¹³	100%^8,9	100%^8,9	Combined Med/Rx ded
Western Health Advantage HMO B	$45 Copay⁵	60% (up to $1,250 per prescription¹¹)^5,12	60% (up to $1,250 per prescription¹¹)^5,12	$500/$1,000
Western Health Advantage HMO C*	100%⁵	100%^5,12	100%^5,12	Combined Med/Rx ded

Bronze Tier PPO/EPO Rx Benefits

Participating Health Plan	Generic		Brand		Non-Formulary		Brand Deductible
	Participating Pharmacy	Non-Participating Pharmacy	Participating Pharmacy	Non-Participating Pharmacy	Participating Pharmacy	Non-Participating Pharmacy	Participating Pharmacy	Non-Participating Pharmacy
Anthem Blue Cross PPO A*	Level 1 $20 Copay/ Level 2 $20 Copay^1,14	Not Covered	Level 1 $90 Copay/ Level 2 $100 Copay^1,14	Not Covered	Level 1 $160 Copay/ Level 2 $170 Copay¹	Not Covered	Combined Med/Rx/Ped dental ded	N/A
Anthem Blue Cross PPO B*	Level 1 $20 Copay/ Level 2 $20 Copay^1,14	Not Covered	Level 1 $90 Copay Level 2 $100 Copay^1,14	Not Covered	Level 1 $160 Copay/ Level 2 $170 Copay¹	Not Covered	Combined Med/Rx/Ped dental ded	N/A
Anthem Blue Cross EPO A	Level 1 $20 Copay/ Level 2 $20 Copay (ded waived)¹	Not Covered	Level 1 $90 Copay/ Level 2 $100 Copay¹	Not Covered	Level 1 $160 Copay/ Level 2 $170 Copay¹	Not Covered	$650/$1,300	N/A
Cigna + Oscar EPO C*	60% (up to $250 per prescription¹¹)	Not Covered	60% (up to $250 per prescription¹¹)	Not Covered	60% (up to $250 per prescription¹¹)	Not Covered	Combined Med/Rx/Ped dental ded	N/A
Cigna + Oscar EPO D	$35 Copay (ded waived)	Not Covered	60% (up to $250 per prescription¹¹)	Not Covered	60% (up to $250 per prescription¹¹)	Not Covered	Combined Med/Rx/Ped dental ded	N/A

Bronze Tier PPO/EPO Mail Order Rx Benefits

90 Day Supply:

Participating Health Plan	Generic	Brand	Non- Formulary	Brand Deductible
Anthem Blue Cross PPO A*	Level 1 $50 Copay^1,14	Level 1 $270 Copay^1,14	Level 1 $480 Copay¹	Combined Med/Rx/Ped dental ded
Anthem Blue Cross PPO B*	Level 1 $50 Copay^1,14	Level 1 $270 Copay^1,14	Level 1 $480 Copay¹	Combined Med/Rx/Ped dental ded
Anthem Blue Cross EPO A	Level 1 $50 Copay(ded waived)¹	Level 1 $270 Copay¹	Level 1 $480 Copay¹	$650/$1,300
Cigna + Oscar EPO C*	60% (up to $750 per prescription¹¹)	60% (up to $750 per prescription¹¹)	60% (up to $750 per prescription¹¹)	Combined Med/Rx/Ped dental ded
Cigna + Oscar EPO D	$105 Copay (ded waived)	60% (up to $750 per prescription¹¹)	60% (up to $750 per prescription¹¹)	Combined Med/Rx/Ped dental ded

*HSA Qualified High Deductible Health Plan

1. The four prescription drug tiers are: tier 1 typically generic drugs and low-cost preferred brand name drugs; tier 2 typically non-preferred generic drugs, preferred brand name drugs; tier 3 typically non-preferred brand name drugs; and tier 4 typically drugs that are biologics or distributed through a specialty pharmacy. Plans use the RxChoice Tiered Network, which includes a choice of two levels of copays -- the first copay listed is for Level 1 pharmacies and the second copay listed is for Level 2.

2. The four prescription drug tiers are Tier 1: Generic formulary; Tier 2: Brand formulary; Tier 3: Brand non-formulary; Tier 4: Specialty.

3. See plan specific EOC for information regarding preventive drugs and women's contraceptives.

4. The brand-name prescription drug deductible (per member, per calendar year) must be paid before Health Net begins to pay for brand-name prescription drugs.

5. Medical or prescription services may be subject to a deductible. The member must pay for these services when services are rendered until the deductible is met in that calendar year. Charges under the deductible are based on WHA's contracted rates with the provider of service.

6. Percentage copayment amounts are based on WHA's contracted rates with the provider of service.

7. Specialty medication is tiered based on their cost efficiency and effectiveness. To see if there is a Specialty equivalent medication in this tier, please visit https://www.uhc.com/member-resources/pharmacy-benefits/prescription-drug-lists.

8. Cost sharing applies per prescription for up to a 30-day supply of prescribed and medically necessary generic or brand-name drugs in accordance with formulary guidelines. Except for specialty drugs, up to a 100-day supply is available, at twice the 30-day retail copayment price, through the mail-order pharmacy. Specialty drugs are available for up to a 30-day supply through the specialty pharmacy. Cost sharing for a 12-month supply of FDA-approved, self-administered hormonal contraceptives, when applicable, will be 12 times the retail cost or four times the mail-order cost. Member cost sharing for oral anti-cancer drugs shall not exceed $250 per prescription for up to a 30-day supply. For HDHP plans, this $250 maximum will not apply until after the deductible is met.

9. Some drugs prescribed for sexual dysfunction, such as Cialis, Levitra or Viagra (or the generic equivalent, if available) are limited to 8 doses per 30-day supply.

10. Covered in full after out-of-pocket maximum is met.

11. Member maximum responsibility.

12. Regardless of medical necessity or generic availability, the member will be responsible for the applicable copayment when a Tier 2 or Tier 3 medication is dispensed. If a Tier 1 medication is available and the member elects to receive a Tier 2 or Tier 3 medication without medial indication from the prescribing physician, the member will be responsible for the difference in cost between the Tier 1 and the purchased medication in addition to the Tier 1 copayment. The amount paid for the difference in cost does not contribute to the the out-of-pocket maximum.

13. Cost sharing applies per prescription for up to a 30-day supply of prescribed and medically necessary generic or brand-name drugs in accordance with formulary guidelines. Except for specialty drugs, up to a 100-day supply is available, at twice the 30-day retail copayment price, through the mail-order pharmacy. Specialty drugs are available for up to a 30-day supply through the specialty pharmacy. Cost sharing for a 12-month supply of FDA-approved, self-administered hormonal contraceptives, when applicable, will be 12 times the retail cost or four times the mail-order cost. Member cost sharing for oral anti-cancer drugs shall not exceed $250 per prescription for up to a 30-day supply. For HDHP plans, this $250 maximum will not apply until after the deductible is met. Some drugs prescribed for sexual dysfunction, such as Cialis, Levitra or Viagra (or the generic equivalent, if available) are limited to 8 doses per 30-day supply.

14. Deductible is waived for drugs on the PreventiveRx Plus drug list.

Effective 4/1/22

Platinum Tier HMO Rx Benefits

Participating Health Plan	Generic	Brand	Non- Formulary	Brand Deductible
Anthem Blue Cross HMO A	Level 1 $5 Copay/ Level 2 $10 Copay¹	Level 1 $20 Copay/ Level 2 $30 Copay¹	Level 1 $50 Copay/ Level 2 $60 Copay¹	N/A
Health Net HMO C	$5 Copay^2,3	$30 Copay^2,3	$50 Copay^2,3	N/A
Health Net HMO D	$5 Copay^2,3	$30 Copay^2,3	$50 Copay^2,3	N/A
Health Net HMO E	$5 Copay^2,3	$30 Copay^2,3	$50 Copay^2,3	N/A
Health Net HMO F	100% ^2,3	$30 Copay^2,3	$50 Copay^2,3	N/A
Health Net HMO G	100% ^2,3	$30 Copay^2,3	$50 Copay^2,3	N/A
Health Net HMO H	100% ^2,3	$30 Copay^2,3	$50 Copay^2,3	N/A
Kaiser Permanente HMO A	$5 Copay	$15 Copay	$15 Copay (with physician approval)	N/A
Kaiser Permanente HMO B	$5 Copay	$20 Copay	$20 Copay (with physician approval)	N/A
Sharp HMO A	$10 Copay	$25 Copay	$50 Copay	N/A
Sharp HMO B	$10 Copay	$25 Copay	$50 Copay	N/A
Sharp HMO C	$10 Copay	$25 Copay	$50 Copay	N/A
Sutter Health Plus HMO A	$5 Copay¹³	$20 Copay^8,9	$30 Copay^8,9	N/A
Sutter Health Plus HMO B	$5 Copay¹³	$15 Copay^8,9	$30 Copay^8,9	N/A
UnitedHealthcare HMO A	Tier 1 Non-specialty $5 Copay / Tier 1 Specialty $5 Copay⁷	Tier 2 Non-specialty $40 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $80 Copay / Tier 3 Specialty $250 Copay⁷	N/A
UnitedHealthcare HMO C	Tier 1 Non-specialty $5 Copay / Tier 1 Specialty $5 Copay⁷	Tier 2 Non-specialty $40 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $80 Copay / Tier 3 Specialty $250 Copay⁷	N/A
UnitedHealthcare HMO E	Tier 1 Non-specialty $5 Copay / Tier 1 Specialty $5 Copay⁷	Tier 2 Non-specialty $40 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $80 Copay / Tier 3 Specialty $250 Copay⁷	N/A
UnitedHealthcare HMO G	Tier 1 Non-specialty $5 Copay / Tier 1 Specialty $5 Copay⁷	Tier 2 Non-specialty $40 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $80 Copay / Tier 3 Specialty $250 Copay⁷	N/A
UnitedHealthcare HMO H	Tier 1 Non-specialty $5 Copay / Tier 1 Specialty $5 Copay⁷	Tier 2 Non-specialty $40 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $80 Copay / Tier 3 Specialty $250 Copay⁷	N/A
UnitedHealthcare HMO I	Tier 1 Non-specialty $5 Copay / Tier 1 Specialty $5 Copay⁷	Tier 2 Non-specialty $40 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $80 Copay / Tier 3 Specialty $250 Copay⁷	N/A
UnitedHealthcare HMO J	Tier 1 Non-specialty $5 Copay / Tier 1 Specialty $5 Copay⁷	Tier 2 Non-specialty $40 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $80 Copay / Tier 3 Specialty $250 Copay⁷	N/A
UnitedHealthcare HMO K	Tier 1 Non-specialty $5 Copay / Tier 1 Specialty $5 Copay⁷	Tier 2 Non-specialty $40 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $80 Copay / Tier 3 Specialty $250 Copay⁷	N/A
UnitedHealthcare HMO L	Tier 1 Non-specialty $5 Copay / Tier 1 Specialty $5 Copay⁷	Tier 2 Non-specialty $40 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $80 Copay / Tier 3 Specialty $250 Copay⁷	N/A
Western Health Advantage HMO A	$10 Copay	$30 Copay¹²	$50 Copay¹²	N/A
Western Health Advantage HMO B	$5 Copay	$20 Copay¹²	$30 Copay¹²	N/A
Western Health Advantage HMO C	$5 Copay	$30 Copay¹²	$50 Copay¹²	N/A

Platinum Tier HMO Mail Order Rx Benefits

90 Day Supply:

Participating Health Plan	Generic	Brand	Non- Formulary	Brand Deductible
Anthem Blue Cross HMO A	Level 1 $13 Copay¹	Level 1 $60 Copay¹	Level 1 $150 Copay¹	N/A
Health Net HMO C	$10 Copay^2,3	$75 Copay^2,3	$125 Copay^2,3	N/A
Health Net HMO D	$10 Copay^2,3	$75 Copay^2,3	$125 Copay^2,3	N/A
Health Net HMO E	$10 Copay^2,3	$75 Copay^2,3	$125 Copay^2,3	N/A
Health Net HMO F	100% ^2,3	$75 Copay^2,3	$125 Copay^2,3	N/A
Health Net HMO G	100% ^2,3	$75 Copay^2,3	$125 Copay^2,3	N/A
Health Net HMO H	100% ^2,3	$75 Copay^2,3	$125 Copay^2,3	N/A
Kaiser Permanente HMO A	$10 Copay	$40 Copay	$40 Copay (with physician Approval)	N/A
Kaiser Permanente HMO B	$10 Copay	$30 Copay	$30 Copay (with physician approval)	N/A
Sharp HMO A	$20 Copay	$50 Copay	$100 Copay	N/A
Sharp HMO B	$20 Copay	$50 Copay	$100 Copay	N/A
Sharp HMO C	$20 Copay	$50 Copay	$100 Copay	N/A
Sutter Health Plus HMO A	$10 Copay¹³	$40 Copay^8,9	$60 Copay^8,9	N/A
Sutter Health Plus HMO B	$10 Copay¹³	$30 Copay^8,9	$60 Copay^8,9	N/A
UnitedHealthcare HMO A	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay⁷	Tier 2 Non-specialty $80 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $160 Copay / Tier 3 Specialty $500 Copay⁷	N/A
UnitedHealthcare HMO C	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay⁷	Tier 2 Non-specialty $80 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $160 Copay / Tier 3 Specialty $500 Copay⁷	N/A
UnitedHealthcare HMO E	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay⁷	Tier 2 Non-specialty $80 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $160 Copay / Tier 3 Specialty $500 Copay⁷	N/A
UnitedHealthcare HMO G	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay⁷	Tier 2 Non-specialty $80 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $160 Copay / Tier 3 Specialty $500 Copay⁷	N/A
UnitedHealthcare HMO H	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay⁷	Tier 2 Non-specialty $80 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $160 Copay / Tier 3 Specialty $500 Copay⁷	N/A
UnitedHealthcare HMO I	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay⁷	Tier 2 Non-specialty $80 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $160 Copay / Tier 3 Specialty $500 Copay⁷	N/A
UnitedHealthcare HMO J	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay⁷	Tier 2 Non-specialty $80 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $160 Copay / Tier 3 Specialty $500 Copay⁷	N/A
UnitedHealthcare HMO K	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay⁷	Tier 2 Non-specialty $80 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $160 Copay / Tier 3 Specialty $500 Copay⁷	N/A
UnitedHealthcare HMO L	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay⁷	Tier 2 Non-specialty $80 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $160 Copay / Tier 3 Specialty $500 Copay⁷	N/A
Western Health Advantage HMO A	$25 Copay	$75 Copay¹²	$125 Copay¹²	N/A
Western Health Advantage HMO B	$13 Copay	$50 Copay¹²	$75 Copay¹²	N/A
Western Health Advantage HMO C	$13 Copay	$75 Copay¹²	$125 Copay¹²	N/A

Platinum Tier PPO/EPO Rx Benefits

Participating Health Plan	Generic		Brand		Non-Formulary		Brand Deductible
	Participating Pharmacy	Non-Participating Pharmacy	Participating Pharmacy	Non-Participating Pharmacy	Participating Pharmacy	Non-Participating Pharmacy	Participating Pharmacy	Non-Participating Pharmacy
Cigna + Oscar EPO C	$5 Copay	Not Covered	$30 Copay	Not Covered	$50 Copay	Not Covered	N/A	N/A
Cigna + Oscar EPO D	$5 Copay (overall ded waived)	Not Covered	$30 Copay (overall ded waived)	Not Covered	$50 Copay (overall ded waived)	Not Covered	N/A	N/A
Cigna + Oscar EPO E	$10 Copay (overall ded waived)	Not Covered	$35 Copay (overall ded waived)	Not Covered	$75 Copay (overall ded waived)	Not Covered	N/A	N/A

Platinum Tier PPO/EPO Mail Order Rx Benefits

90 Day Supply:

Participating Health Plan	Generic	Brand	Non- Formulary	Brand Deductible
Cigna + Oscar EPO C	$15 Copay	$90 Copay	$150 Copay	N/A
Cigna + Oscar EPO D	$15 Copay (overall ded waived)	$90 Copay (overall ded waived)	$150 Copay (overall ded waived)	N/A
Cigna + Oscar EPO E	$30 Copay (overall ded waived)	$105 Copay (overall ded waived)	$225 Copay (overall ded waived)	N/A

Gold Tier HMO Rx Benefits

Participating Health Plan	Generic	Brand	Non- Formulary	Brand Deductible
Anthem Blue Cross HMO A	Level 1 $10 Copay/ Level 2 $20 Copay¹	Level 1 $50 Copay/ Level 2 $60 Copay¹	Level 1 $90 Copay/ Level 2 $100 Copay¹	N/A
Anthem Blue Cross HMO B	Level 1 $10 Copay/ Level 2 $20 Copay¹	Level 1 $50 Copay/ Level 2 $60 Copay¹	Level 1 $90 Copay/ Level 2 $100 Copay¹	N/A
Anthem Blue Cross HMO C	Level 1 $10 Copay/ Level 2 $20 Copay¹	Level 1 $50 Copay/ Level 2 $60 Copay¹	Level 1 $90 Copay/ Level 2 $100 Copay¹	N/A
Health Net HMO A	$15 Copay^2,3	$50 Copay^2,3	$70 Copay^2,3	N/A
Health Net HMO B	$15 Copay^2,3	$50 Copay^2,3	$70 Copay^2,3	N/A
Health Net HMO C	$15 Copay^2,3	$50 Copay^2,3	$70 Copay^2,3	N/A
Health Net HMO D	$15 Copay^2,3	$50 Copay^2,3	$70 Copay^2,3	N/A
Health Net HMO E	$15 Copay^2,3	$50 Copay^2,3	$70 Copay^2,3	N/A
Health Net HMO F	$15 Copay^2,3	$50 Copay^2,3	$70 Copay^2,3	N/A
Health Net HMO G	$15 Copay^2,3	$50 Copay^2,3	$70 Copay^2,3	N/A
Kaiser Permanente HMO B	$15 Copay (overall ded waived)	$40 Copay (overall ded waived)	$40 Copay (overall ded waived; with physician approval)	N/A
Kaiser Permanente HMO C	$15 Copay	$40 Copay	$40 Copay ( with physician approval)	N/A
Kaiser Permanente HMO D	$20 Copay (ded waived)	$50 Copay	$50 Copay ( with physician approval)	$250/$500
Kaiser Permanente HMO E*	$15 Copay	$45 Copay	$45 Copay ( with physician approval)	Combined Med/Rx ded
Sharp HMO A	$16 Copay (ded waived)	$35 Copay	$70 Copay	$200/$400
Sharp HMO B	$16 Copay (ded waived)	$40 Copay	$75 Copay	$400/$800
Sharp HMO D	$16 Copay	$35 Copay	$70 Copay	N/A
Sutter Health Plus HMO A	$5 Copay (overall ded waived)¹³	$15 Copay (overall ded waived)^8,9	$30 Copay (overall ded waived)^8,9	N/A
Sutter Health Plus HMO B	$15 Copay (overall ded waived)¹³	$40 Copay (overall ded waived)^8,9	$70 Copay (overall ded waived)^8,9	N/A
UnitedHealthcare HMO A	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay (ded waived)⁷	Tier 2 Non-specialty $50 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $100 Copay / Tier 3 Specialty $250 Copay⁷	$250/$500
UnitedHealthcare HMO B	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay (ded waived)⁷	Tier 2 Non-specialty $50 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $100 Copay / Tier 3 Specialty $250 Copay⁷	$250/$500
UnitedHealthcare HMO F	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay (ded waived)⁷	Tier 2 Non-specialty $50 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $100 Copay / Tier 3 Specialty $250 Copay⁷	$100/$200
UnitedHealthcare HMO G	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay (ded waived)⁷	Tier 2 Non-specialty $50 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $100 Copay / Tier 3 Specialty $250 Copay⁷	$100/$200
UnitedHealthcare HMO H	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay (ded waived)⁷	Tier 2 Non-specialty $50 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $100 Copay / Tier 3 Specialty $250 Copay⁷	$250/$500
UnitedHealthcare HMO J	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay (ded waived)⁷	Tier 2 Non-specialty $50 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $100 Copay / Tier 3 Specialty $250 Copay⁷	$250/$500
UnitedHealthcare HMO L	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay (ded waived)⁷	Tier 2 Non-specialty $50 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $100 Copay / Tier 3 Specialty $250 Copay⁷	$250/$500
UnitedHealthcare HMO M	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay (ded waived)⁷	Tier 2 Non-specialty $50 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $100 Copay / Tier 3 Specialty $250 Copay⁷	$100/$200
UnitedHealthcare HMO N	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay (ded waived)⁷	Tier 2 Non-specialty $50 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $100 Copay / Tier 3 Specialty $250 Copay⁷	$250/$500
UnitedHealthcare HMO O	Tier 1 Non-specialty $5 Copay / Tier 1 Specialty $5 Copay (ded waived)⁷	Tier 2 Non-specialty $50 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $100 Copay / Tier 3 Specialty $250 Copay⁷	$250/$500
UnitedHealthcare HMO P	Tier 1 Non-specialty $5 Copay / Tier 1 Specialty $5 Copay (ded waived)⁷	Tier 2 Non-specialty $50 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $100 Copay / Tier 3 Specialty $250 Copay⁷	$250/$500
UnitedHealthcare HMO Q	Tier 1 Non-specialty $5 Copay / Tier 1 Specialty $5 Copay (ded waived)⁷	Tier 2 Non-specialty $50 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $100 Copay / Tier 3 Specialty $250 Copay⁷	$250/$500
Western Health Advantage HMO A	$20 Copay	$50 Copay ¹²	$75 Copay¹²	N/A
Western Health Advantage HMO B	$15 Copay (overall ded waived)	$40 Copay (overall ded waived)¹²	$70 Copay (overall ded waived)¹²	N/A
Western Health Advantage HMO C	$10 Copay (ded waived)	$50 Copay ^5,12	$75 Copay^5,12	$500/$1,000
Western Health Advantage HMO D*	100%⁵	$30 Copay^5,12	$50 Copay^5,12	Combined Med/Rx ded

Gold Tier HMO Mail Order Rx Benefits

90 Day Supply:

Participating Health Plan	Generic	Brand	Non- Formulary	Brand Deductible
Anthem Blue Cross HMO A	Level 1 $25 Copay¹	Level 1 $150 Copay¹	Level 1 $270 Copay¹	N/A
Anthem Blue Cross HMO B	Level 1 $25 Copay¹	Level 1 $150 Copay¹	Level 1 $270 Copay¹	N/A
Anthem Blue Cross HMO C	Level 1 $25 Copay¹	Level 1 $150 Copay¹	Level 1 $270 Copay¹	N/A
Health Net HMO A	$30 Copay^2,3	$125 Copay^2,3	$175 Copay^2,3	N/A
Health Net HMO B	$30 Copay^2,3	$125 Copay^2,3	$175 Copay^2,3	N/A
Health Net HMO C	$30 Copay^2,3	$125 Copay^2,3	$175 Copay^2,3	N/A
Health Net HMO D	$30 Copay^2,3	$125 Copay^2,3	$175 Copay^2,3	N/A
Health Net HMO E	$30 Copay^2,3	$125 Copay^2,3	$175 Copay^2,3	N/A
Health Net HMO F	$30 Copay^2,3	$125 Copay^2,3	$175 Copay^2,3	N/A
Health Net HMO G	$30 Copay^2,3	$125 Copay^2,3	$175 Copay^2,3	N/A
Kaiser Permanente HMO B	$30 Copay (overall ded waived)	$80 Copay (overall ded waived)	$80 Copay (overall ded waived; with physician approval)	$250/$500
Kaiser Permanente HMO C	$30 Copay	$80 Copay	$80 Copay (with physician approval)	N/A
Kaiser Permanente HMO D	$40 Copay (ded waived)	$100 Copay	$100 Copay (with physician approval)	$250/$500
Kaiser Permanente HMO E*	$30 Copay	$90 Copay	$90 Copay (with physician approval)	Combined Med/Rx ded
Sharp HMO A	$32 Copay (ded waived)	$70 Copay	$140 Copay	$200/$400
Sharp HMO B	$32 Copay (ded waived)	$80 Copay	$150 Copay	$400/$800
Sharp HMO D	$32 Copay	$70 Copay	$140 Copay	N/A
Sutter Health Plus HMO A	$10 Copay (overall ded waived)¹³	$30 Copay (overall ded waived)^8,9	$60 Copay (overall ded waived)^8,9	N/A
Sutter Health Plus HMO B	$30 Copay (overall ded waived)¹³	$80 Copay (overall ded waived)^8,9	$140 Copay (overall ded waived)^8,9	N/A
UnitedHealthcare HMO A	Tier 1 Non-specialty $20 Copay / Tier 1 Specialty $20 Copay (ded waived)⁷	Tier 2 Non-specialty $100 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $200 Copay / Tier 3 Specialty $500 Copay⁷	$250/$500
UnitedHealthcare HMO B	Tier 1 Non-specialty $20 Copay / Tier 1 Specialty $20 Copay (ded waived)⁷	Tier 2 Non-specialty $100 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $200 Copay / Tier 3 Specialty $500 Copay⁷	$250/$500
UnitedHealthcare HMO F	Tier 1 Non-specialty $20 Copay / Tier 1 Specialty $20 Copay (ded waived)⁷	Tier 2 Non-specialty $100 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $200 Copay / Tier 3 Specialty $500 Copay⁷	$100/$200
UnitedHealthcare HMO G	Tier 1 Non-specialty $20 Copay / Tier 1 Specialty $20 Copay (ded waived)⁷	Tier 2 Non-specialty $100 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $200 Copay / Tier 3 Specialty $500 Copay⁷	$100/$200
UnitedHealthcare HMO H	Tier 1 Non-specialty $20 Copay / Tier 1 Specialty $20 Copay (ded waived)⁷	Tier 2 Non-specialty $100 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $200 Copay / Tier 3 Specialty $500 Copay⁷	$250/$500
UnitedHealthcare HMO J	Tier 1 Non-specialty $20 Copay / Tier 1 Specialty $20 Copay (ded waived)⁷	Tier 2 Non-specialty $100 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $200 Copay / Tier 3 Specialty $500 Copay⁷	$250/$500
UnitedHealthcare HMO L	Tier 1 Non-specialty $20 Copay / Tier 1 Specialty $20 Copay (ded waived)⁷	Tier 2 Non-specialty $100 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $200 Copay / Tier 3 Specialty $500 Copay⁷	$250/$500
UnitedHealthcare HMO M	Tier 1 Non-specialty $20 Copay / Tier 1 Specialty $20 Copay (ded waived)⁷	Tier 2 Non-specialty $100 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $200 Copay / Tier 3 Specialty $500 Copay⁷	$100/$200
UnitedHealthcare HMO N	Tier 1 Non-specialty $20 Copay / Tier 1 Specialty $20 Copay (ded waived)⁷	Tier 2 Non-specialty $100 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $200 Copay / Tier 3 Specialty $500 Copay⁷	$250/$500
UnitedHealthcare HMO O	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay (ded waived)⁷	Tier 2 Non-specialty $100 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $200 Copay / Tier 3 Specialty $500 Copay⁷	$250/$500
UnitedHealthcare HMO P	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay (ded waived)⁷	Tier 2 Non-specialty $100 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $200 Copay / Tier 3 Specialty $500 Copay⁷	$250/$500
UnitedHealthcare HMO Q	Tier 1 Non-specialty $10 Copay / Tier 1 Specialty $10 Copay (ded waived)⁷	Tier 2 Non-specialty $100 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $200 Copay / Tier 3 Specialty $500 Copay⁷	$250/$500
Western Health Advantage HMO A	$50 Copay	$125 Copay¹²	$188 Copay¹²	N/A
Western Health Advantage HMO B	$38 Copay (overall ded waived)	$100 Copay (overall ded waived)^5,12	$175 Copay (overall ded waived)^5,12	N/A
Western Health Advantage HMO C	$25 Copay (ded waived)	$125 Copay^5,12	$188 Copay^5,12	$500/$1,000
Western Health Advantage HMO D*	100%⁵	$75 Copay^5,12	$125 Copay^5,12	Combined Med/Rx ded

Gold Tier PPO/EPO Rx Benefits

Participating Health Plan	Generic		Brand		Non-Formulary		Brand Deductible
	Participating Pharmacy	Non-Participating Pharmacy	Participating Pharmacy	Non-Participating Pharmacy	Participating Pharmacy	Non-Participating Pharmacy	Participating Pharmacy	Non-Participating Pharmacy
Anthem Blue Cross PPO A	Level 1 $10 Copay/ Level 2 $20 Copay (ded waived)¹	Not Covered	Level 1 $50 Copay/ Level 2 $60 Copay¹	Not Covered	Level 1 $90 Copay/ Level 2 $100 Copay¹	Not Covered	$250/$500	N/A
Anthem Blue Cross PPO B	Level 1 $10 Copay/ Level 2 $20 Copay (ded waived)¹	Not Covered	Level 1 $50 Coapy/ Level 2 $60 Copay¹	Not Covered	Level 1 $90 Copay/ Level 2 $100 Copay¹	Not Covered	$250/$500	N/A
Anthem Blue Cross PPO C	Level 1 $10 Copay/ Level 2 $20 Copay (ded waived)¹	Not Covered	Level 1 $50 Copay/ Level 2 $60 Copay¹	Not Covered	Level 1 $90 Copay/ Level 2 $100 Copay¹	Not Covered	$150/$300	N/A
Anthem Blue Cross PPO D	Level 1 $10 Copay/ Level 2 $20 Copay (ded waived)¹	Not Covered	Level 1 $50 Copay/ Level 2 $60 Copay¹	Not Covered	Level 1 $90 Copay/ Level 2 $100 Copay¹	Not Covered	$250/$500	N/A
Anthem Blue Cross PPO E	Level 1 $10 Copay/ Level 2 $20 Copay (ded waived)¹	Not Covered	Level 1 $50 Copay/ Level 2 $60 Copay¹	Not Covered	Level 1 $90 Copay/ Level 2 $100 Copay¹	Not Covered	$150/$300	N/A
Cigna + Oscar EPO C	$15 Copay	Not Covered	$40 Copay	Not Covered	$90 Copay	Not Covered	N/A	N/A
Cigna + Oscar EPO D	$15 Copay (ded waived)	Not Covered	$45 Copay	Not Covered	$90 Copay	Not Covered	$300/$600	N/A
Cigna + Oscar EPO E	$15 Copay (ded waived)	Not Covered	$45 Copay	Not Covered	$90 Copay	Not Covered	$300/$600	N/A

Gold Tier PPO/EPO Mail Order Rx Benefits

90 Day Supply:

Participating Health Plan	Generic	Brand	Non- Formulary	Brand Deductible
Anthem Blue Cross PPO A	Level 1 $25 Copay(ded waived)¹	Level 1 $150 Copay¹	Level 1 $270 Copay¹	$250/$500
Anthem Blue Cross PPO B	Level 1 $25 Copay(ded waived)¹	Level 1 $150 Copay¹	Level 1 $270 Copay¹	$250/$500
Anthem Blue Cross PPO C	Level 1 $25 Copay(ded waived)¹	Level 1 $150 Copay¹	Level 1 $270 Copay¹	$150/$300
Anthem Blue Cross PPO D	Level 1 $25 Copay (ded waived)¹	Level 1 $150 Copay¹	Level 1 $270 Copay¹	$250/$500
Anthem Blue Cross PPO E	Level 1 $25 Copay (ded waived)¹	Level 1 $150 Copay¹	Level 1 $270 Copay¹	$150/$300
Cigna + Oscar EPO C	$45 Copay	$120 Copay	$270 Copay	N/A
Cigna + Oscar EPO D	$45 Copay(ded waived)	$135 Copay	$270 Copay	$300/$600
Cigna + Oscar EPO E	$45 Copay (ded waived)	$135 Copay	$270 Copay	$300/$600

Silver Tier HMO Rx Benefits

Participating Health Plan	Generic	Brand	Non- Formulary	Brand Deductible
Anthem Blue Cross HMO A	Level 1 $15 Copay/ Level 2 $20 Copay (ded waived)¹	Level 1 $70 Copay/ Level 2 $80 Copay¹	Level 1 $110 Copay/ Level 2 $120 Copay¹	$300/$600
Anthem Blue Cross HMO B	Level 1 $15 Copay/ Level 2 $20 Copay (ded waived)¹	Level 1 $70 Copay/ Level 2 $80 Copay¹	Level 1 $110 Copay/ Level 2 $120 Copay¹	$300/$600
Anthem Blue Cross HMO C	Level 1 $15 Copay/ Level 2 $20 Copay (ded waived)¹	Level 1 $70 Copay/ Level 2 $80 Copay¹	Level 1 $110 Copay/ Level 2 $120 Copay¹	$300/$600
Health Net HMO A	$20 Copay^2,3	$50% (up to $250 per prescription¹¹)^2,3	50% (up to $250 per prescription¹¹)^2,3	$750/$1,500
Health Net HMO C	$15 Copay (ded waived)^2,3	60% (up to $250 per prescription¹¹)^2,3	60% (up to $250 per prescription¹¹)^2,3	$250/$500
Kaiser Permanente HMO A	$20 Copay (ded waived)	$75 Copay	$75 Copay (with physician approval)	$500/$1,000
Kaiser Permanente HMO B	$20 Copay (ded waived)	$75 Copay	$75 Copay (with physician approval)	$350/$700
Kaiser Permanente HMO C	$17 Copay (ded waived)	$80 Copay	$80 Copay (with physician approval)	$300/$600
Kaiser Permanente HMO D*	80% (up to $250 per prescription¹¹)	80% (up to $250 per prescription¹¹)	80% (up to $250 per prescription¹¹)(with physician approval)	Combined Med/Rx ded
Kaiser Permanente HMO E	$20 Copay (ded waived)	$75 Copay	$75 Copay (with physician approval)	Combined Med/Rx ded
Sharp HMO A	$16 Copay (ded waived)	$105 Copay	$135 Copay	$250/$500
Sharp HMO B	$16 Copay (ded waived)	$100 Copay	$160 Copay	$250/$500
Sharp HMO C	$160 Copay (overall ded waived)	$100 Copay (overall ded waived)	$150 Copay (overall ded waived)	N/A
Sutter Health Plus HMO B	$17 Copay (ded waived)¹³	$80 Copay^8,9	$110 Copay^8,9	$300/$600
Sutter Health Plus HMO C*	$10 Copay¹³	$20 Copay^8,9	$40 Copay^8,9	Combined Med/ Rx ded
UnitedHealthcare HMO A	Tier 1 Non-specialty $20 Copay / Tier 1 Specialty $20 Copay (ded waived)⁷	Tier 2 Non-specialty $80 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $125 Copay / Tier 3 Specialty $250 Copay⁷	$400/$800
UnitedHealthcare HMO E	Tier 1 Non-specialty $20 Copay / Tier 1 Specialty $20 Copay (ded waived)⁷	Tier 2 Non-specialty $80 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $125 Copay / Tier 3 Specialty $250 Copay⁷	$400/$800
UnitedHealthcare HMO F	Tier 1 Non-specialty $20 Copay / Tier 1 Specialty $20 Copay (ded waived)⁷	Tier 2 Non-specialty $80 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $125 Copay / Tier 3 Specialty $250 Copay⁷	$400/$800
UnitedHealthcare HMO G	Tier 1 Non-specialty $15 Copay / Tier 1 Specialty $15 Copay (ded waived)⁷	Tier 2 Non-specialty $75 Copay / Tier 2 Specialty $150 Copay⁷	Tier 3 Non-specialty $125 Copay / Tier 3 Specialty $250 Copay⁷	$400/$800
Western Health Advantage HMO A	$15 Copay (ded waived)	$55 Copay^5,12	$85 Copay^5,12	$250/$500
Western Health Advantage HMO B	$17 Copay (ded waived)	$80 Copay^5,12	$110 Copay^5,12	$300/$600
Western Health Advantage HMO C*	80% (up to $250 per 30 day supply¹¹)^5,6	80% (up to $250 per 30 day supply¹¹)^5,6,12	80% (up to $250 per 30 day supply¹¹)^5,6,12	Combined Med/Rx ded

Silver Tier HMO Mail Order Rx Benefits

90 Day Supply:

Participating Health Plan	Generic	Brand	Non- Formulary	Brand Deductible
Anthem Blue Cross HMO A	Level 1 $38 Copay (ded waived)¹	Level 1 $210 Copay¹	Level 1 $330 Copay¹	$300/$600
Anthem Blue Cross HMO B	Level 1 $38 Copay (ded waived)¹	Level 1 $210 Copay¹	Level 1 $330 Copay¹	$300/$600
Anthem Blue Cross HMO C	Level 1 $38 Copay (ded waived)¹	Level 1 $210 Copay¹	Level 1 $330 Copay¹	$300/$600
Health Net HMO A	$40 Copay^2,3	50% (up to $750 per prescription¹¹)^2,3	50% (up to $750 per prescription¹¹)^2,3	$750/$1,500
Health Net HMO C	$30 Copay (ded waived)^2,3	60% (up to $750 per prescription¹¹)^2,3	60% (up to $750 per prescription¹¹)^2,3	$250/$500
Kaiser Permanente HMO A	$40 Copay (ded waived)	$150 Copay	$150 Copay (with physician approval)	$500/$1,000
Kaiser Permanente HMO B	$40 Copay (ded waived)	$150 Copay	$150 Copay (with physician approval)	$350/$700
Kaiser Permanente HMO C	$34 Copay (ded waived)	$160 Copay	$160 Copay (with physician approval)	$500/$1,000
Kaiser Permanente HMO D*	80% (up to $500 per prescription¹¹)	80% (up to $500 per prescription¹¹)	80% (up to $500 per prescription¹¹) (with physician approval)	Combined Med/Rx ded
Kaiser Permanente HMO E	$40 Copay (ded waived)	$150 Copay	$150 Copay (with physician approval)	Combined Med/Rx ded
Sharp HMO A	$32 Copay (ded waived)	$210 Copay	$270 Copay	$250/$500
Sharp HMO B	$32 Copay (ded waived)	$200 Copay	$320 Copay	$250/$500
Sharp HMO C	$32 Copay (overall ded waived)	$200 Copay	$300 Copay	N/A
Sutter Health Plus HMO B	$34 Copay (ded waived)¹³	$160 Copay^8,9	$220 Copay^8,9	$300/$600
Sutter Health Plus HMO C*	$20 Copay¹³	$40 Copay^8,9	$80 Copay^8,9	Combined Med/Rx ded
UnitedHealthcare HMO A	Tier 1 Non-specialty $40 Copay / Tier 1 Specialty $40 Copay (ded waived)⁷	Tier 2 Non-specialty $160 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $250 Copay / Tier 3 Specialty $500 Copay⁷	$400/$800
UnitedHealthcare HMO E	Tier 1 Non-specialty $40 Copay / Tier 1 Specialty $40 Copay (ded waived)⁷	Tier 2 Non-specialty $160 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $250 Copay / Tier 3 Specialty $500 Copay⁷	$400/$800
UnitedHealthcare HMO F	Tier 1 Non-specialty $40 Copay / Tier 1 Specialty $40 Copay (ded waived)⁷	Tier 2 Non-specialty $160 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $250 Copay / Tier 3 Specialty $500 Copay⁷	$400/$800
UnitedHealthcare HMO G	Tier 1 Non-specialty $30 Copay / Tier 1 Specialty $30 Copay (ded waived)⁷	Tier 2 Non-specialty $150 Copay / Tier 2 Specialty $300 Copay⁷	Tier 3 Non-specialty $250 Copay / Tier 3 Specialty $500 Copay⁷	$400/$800
Western Health Advantage HMO A	$38 Copay (ded waived)	$138 Copay^5,12	$213 Copay^5,12	$250/$500
Western Health Advantage HMO B	$43 Copay (ded waived)	$200 Copay^5,12	$275 Copay^5,12	$300/$600
Western Health Advantage HMO C*	80% (up to $625 per prescription¹¹)^5,6	80% (up to $625 per prescription¹¹)^5,6,12	80% (up to $625 per prescription¹¹)^5,6,12	Combined Med/Rx ded

Silver Tier PPO/EPO Rx Benefits

Participating Health Plan	Generic		Brand		Non-Formulary		Brand Deductible
	Participating Pharmacy	Non-Participating Pharmacy	Participating Pharmacy	Non-Participating Pharmacy	Participating Pharmacy	Non-Participating Pharmacy	Participating Pharmacy	Non-Participating Pharmacy
Anthem Blue Cross PPO A	Level 1 $15 Copay/ Level 2 $20 Copay (ded waived)¹	Not Covered	Level 1 $70 Copay/ Level 2 $80 Copay¹	Not Covered	Level 1 $110 Copay/ Level 2 $120 Copay¹	Not Covered	$300/$600	N/A
Anthem Blue Cross PPO B	Level 1 $15 Copay/ Level 2 $20 Copay (ded waived)¹	Not Covered	Level 1 $70 Copay/ Level 2 $80 Copay¹	Not Covered	Level 1 $110 Copay/ Level 2 $120 Copay¹	Not Covered	$300/$600	N/A
Anthem Blue Cross PPO C	Level 1 $15 Copay/ Level 2 $20 Copay (ded waived)¹	Not Covered	Level 1 $70 Copay/ Level 2 $80 Copay¹	Not Covered	Level 1 $110 Copay/ Level 2 $120 Copay¹	Not Covered	$300/$600	N/A
Anthem Blue Cross EPO A	Level 1 $15 Copay/ Level 2 $20 Copay (ded waived)^1,14	Not Covered	Level 1 $70 Copay/ Level 2 $80 Copay^1,14	Not Covered	Level 1 $110 Copay/ Level 2 $120 Copay¹	Not Covered	$300/$600	N/A
Anthem Blue Cross EPO B*	Level 1 $15 Copay / Level 2 $20 Copay)¹	Not Covered	Level 1 $70 Copay / Level 2 $80 Copay¹	Not Covered	Level 1 $110 Copay / Level 2 $120 Copay¹	Not Covered	Combined Med/Rx/Ped Dental ded	N/A
Cigna + Oscar EPO C	$25 Copay (ded waived)	Not Covered	$75 Copay	Not Covered	$125 Copay	Not Covered	$250/$500	N/A
Cigna + Oscar EPO D	$25 Copay(overall ded waived)	Not Covered	$75 Copay(overall ded waived)	Not Covered	$125 Copay(overall ded waived)	Not Covered	N/A	N/A
Cigna + Oscar EPO E*	$20 Copay	Not Covered	$60 Copay	Not Covered	$100 Copay	Not Covered	Combined Med/Rx/Ped Dental ded	N/A

Silver Tier PPO/EPO Mail Order Rx Benefits

90 Day Supply:

Participating Health Plan	Generic	Brand	Non- Formulary	Brand Deductible
Anthem Blue Cross PPO A	Level 1 $38 Copay(ded waived)¹	Level 1 $210 Copay¹	Level 1 $330 Copay¹	$300/$600
Anthem Blue Cross PPO B	Level 1 $38 Copay(ded waived)¹	Level 1 $210 Copay¹	Level 1 $330 Copay¹	$300/$600
Anthem Blue Cross PPO C	Level 1 $38 Copayded waived)¹	Level 1 $210 Copay¹	Level 1 $330 Copay¹	$300/$600
Anthem Blue Cross EPO A	Level 1 $38 Copay (ded waived)¹	Level 1 $210 Copay¹	Level 1 $330 Copay¹	$300/$600
Anthem Blue Cross EPO B*	Level 1 $38 Copay^1,14	Level 1 $210 Copay^1,14	Level 1 $330 Copay¹	Combined Med/Rx/Ped dental ded
Cigna + Oscar EPO C	$75 Copay(ded waived)	$225 Copay	$375 Copay	$250/$500
Cigna + Oscar EPO D	$75 Copay(overall ded waived)	$225 Copay(overall ded waived)	$375 Copay(overall ded waived)	N/A
Cigna + Oscar EPO E*	$60 Copay	$180 Copay	$300 Copay	Combined Med/Rx/Ped dental ded

Bronze Tier HMO Rx Benefits

Participating Health Plan	Generic	Brand	Non- Formulary	Brand Deductible
Health Net HMO A	$18 Copay^2,3	60% (up to $500 per prescription¹¹)^2,3	60% (up to $500 per prescription¹¹)^2,3	$500/$1,000
Kaiser Permanente HMO A	$18 Copay	60% (up to $500 per prescription¹¹)	60% (up to $500 per prescription¹¹;with physician approval)	$500/$1,000
Kaiser Permanente HMO B	$20 Copay (ded waived)	50% (up to $500 per prescription¹¹)	50% (up to $500 per prescription¹¹;with physician approval)	Combined Med/Rx ded
Kaiser Permanente HMO C*	100%	100%	100% (with physician approval)	Combined Med/Rx ded
Sharp HMO A	$16 Copay (overall ded waived)	$60 Copay (overall ded waived)	$100 Copay (overall ded waived)	N/A
Sharp HMO B	60% (up to $500 per prescription¹¹)	60% (up to $500 per prescription¹¹)	60% (up to $500 per prescription¹¹)	Combined Med/Rx ded
Sutter Health Plus HMO A	$18 Copy¹³	60% (up to $500 per prescription¹¹)^8,9	60% (up to $500 per prescription¹¹)^8,9	$500/$1,000
Sutter Health Plus HMO B*	100%¹³	100%^8,9	100%^8,9	Combined Med/Rx ded
Western Health Advantage HMO B	$18 Copay⁵	60% (up to $500 per prescription¹¹)^5,12	60% (up to $500 per prescription¹¹)^5,12	$500/$1,000
Western Health Advantage HMO C*	100%⁵	100%^5,12	100%^5,12	Combined Med/Rx ded

Bronze Tier HMO Mail Order Rx Benefits

90 Day Supply:

Participating Health Plan	Generic	Brand	Non- Formulary	Brand Deductible

Health Net HMO A	$36 Copay^2,3	60% (up to $1,500 per prescription¹¹)^2,3	50% (up to $1,500 per prescription¹¹)^2,3	$500/$1,000
Kaiser Permanente HMO A	$36 Copay	60% (up to $1,000 per prescription¹¹)	60% (up to $1,000 per prescription¹¹;with physician approval)	$500/$1,000
Kaiser Permanente HMO B	$40 Copay (ded waived)	50% (up to $1,000 per prescription¹¹)	50% (up to $1,000 per prescription¹¹;with physician approval)	Combined Med/Rx ded
Kaiser Permanente HMO C*	100%	100%	100% (with physician approval)	Combined Med/Rx ded
Sharp HMO A	$32 Copay (overall ded waived)	$120 Copay (overall ded waived)	$200 Copay (overall ded waived)	N/A
Sharp HMO B*	60% (up to $1,000 per prescription¹¹)	60% (up to $1,000 per prescription¹¹)	60% (up to $1,000 per prescription¹¹)	Combined Med/Rx ded
Sutter Health Plus HMO A	$36 Copay¹³	60% (up to $1,000 per prescription¹¹)^8,9	60% (up to $1,000 per prescription¹¹)^8,9	$500/$1,000
Sutter Health Plus HMO B*	100%¹³	100%^8,9	100%^8,9	Combined Med/Rx ded
Western Health Advantage HMO B	$45 Copay⁵	60% (up to $1,250 per prescription¹¹)^5,12	60% (up to $1,250 per prescription¹¹)^5,12	$500/$1,000
Western Health Advantage HMO C*	100%⁵	100%^5,12	100%^5,12	Combined Med/Rx ded

Bronze Tier PPO/EPO Rx Benefits

Participating Health Plan	Generic		Brand		Non-Formulary		Brand Deductible
	Participating Pharmacy	Non-Participating Pharmacy	Participating Pharmacy	Non-Participating Pharmacy	Participating Pharmacy	Non-Participating Pharmacy	Participating Pharmacy	Non-Participating Pharmacy
Anthem Blue Cross PPO A*	Level 1 $20 Copay/ Level 2 $20 Copay^1,14	Not Covered	Level 1 $90 Copay/ Level 2 $100 Copay^1,14	Not Covered	Level 1 $160 Copay/ Level 2 $170 Copay¹	Not Covered	Combined Med/Rx/Ped dental ded	N/A
Anthem Blue Cross PPO B*	Level 1 $20 Copay/ Level 2 $20 Copay^1,14	Not Covered	Level 1 $90 Copay Level 2 $100 Copay^1,14	Not Covered	Level 1 $160 Copay/ Level 2 $170 Copay¹	Not Covered	Combined Med/Rx/Ped dental ded	N/A
Anthem Blue Cross EPO A	Level 1 $20 Copay/ Level 2 $20 Copay (ded waived)¹	Not Covered	Level 1 $90 Copay/ Level 2 $100 Copay¹	Not Covered	Level 1 $160 Copay/ Level 2 $170 Copay¹	Not Covered	$650/$1,300	N/A
Cigna + Oscar EPO C*	60% (up to $250 per prescription¹¹)	Not Covered	60% (up to $250 per prescription¹¹)	Not Covered	60% (up to $250 per prescription¹¹)	Not Covered	Combined Med/Rx/Ped dental ded	N/A
Cigna + Oscar EPO D	$35 Copay (ded waived)	Not Covered	60% (up to $250 per prescription¹¹)	Not Covered	60% (up to $250 per prescription¹¹)	Not Covered	Combined Med/Rx/Ped dental ded	N/A

Bronze Tier PPO/EPO Mail Order Rx Benefits

90 Day Supply:

Participating Health Plan	Generic	Brand	Non- Formulary	Brand Deductible
Anthem Blue Cross PPO A*	Level 1 $50 Copay^1,14	Level 1 $270 Copay^1,14	Level 1 $480 Copay¹	Combined Med/Rx/Ped dental ded
Anthem Blue Cross PPO B*	Level 1 $50 Copay^1,14	Level 1 $270 Copay^1,14	Level 1 $480 Copay¹	Combined Med/Rx/Ped dental ded
Anthem Blue Cross EPO A	Level 1 $50 Copay(ded waived)¹	Level 1 $270 Copay¹	Level 1 $480 Copay¹	$650/$1,300
Cigna + Oscar EPO C*	60% (up to $750 per prescription¹¹)	60% (up to $750 per prescription¹¹)	60% (up to $750 per prescription¹¹)	Combined Med/Rx/Ped dental ded
Cigna + Oscar EPO D	$105 Copay (ded waived)	60% (up to $750 per prescription¹¹)	60% (up to $750 per prescription¹¹)	Combined Med/Rx/Ped dental ded