EPO 70/30/$3,000 Deductible Plan

Medical Plan (In-Network Benefits Only)
Total Deductible $3,000 (Single); $9,000 (with Dependents)
HRA Allocation (City Contribution) N/A
Coinsurance (After Deductible) Member pays 30%; Plan pays 70%
Preventive Services (See SPD for Injections) Plan pays 100%
Outpatient Services Plan pays 70% after Deductible
Inpatient Services Plan pays 70% after Deductible
ER Services at Hospital $100 Copay plus Plan pays 70% after Deductible
Specialist Services & Urgent Care Services Plan pays 70% after Deductible
Out-of-Pocket Max (Combined with Pharmacy) $6,350 (Single); $12,700 (with Dependents)
Rx Coverage (CVS Caremark) See Pharmacy section for more details
Rx Deductible $750 Individual

EPO 75/25 HRA Plan

Medical Plan (In-Network Benefits Only
WellPoints Incentive Earned WellPoints Incentive NOT Earned
Total Deductible $2,500 (Single); $5,000 (with Dependents) $2,500 (Single); $5,000 (with Dependents)
HRA Allocation (City $$$) $1,000 (Single); $2,000 (with Dependents) $700 (Single); $1,700 (with Dependents)
Deductible (Your $$ after City $$) $1,500 (Single); $3,000 (with Dependents) $1,800 (Single); $3,300 (with Dependents)
Maximum Fund Balance $6,000 $6,000
Coinsurance (After Deductible) Member pays 25%; Plan pays 75%
Preventive Services (See SPD for Injections) Plan pays 100% (In-Network only) Doesn't Reduce HRA
Outpatient Services Plan pays 75% after Deductible
Inpatient Services Plan pays 75% after Deductible
ER Services at Hospital (See SPD for Ambulance Services) Plan pays 75% after Deductible
Specialist Services & Urgent Care Services Plan pays 75% after Deductible
Out-of-Pocket Max $6,350 (Single); $12,700 (with Dependents)
Rx Coverage (CVS Caremark) See Pharmacy section for more details
Rx Deductible Same as Deductible above

See the Medical Video for more information on the UnitedHealthcare Benefits.

Prescription Benefit

  70/30 Plan HRA Plan
Generic Medications
Ask your doctor or other prescriber if there is a generic available, as these generally cost less. 10% ($10 minimum) 10%
Preferred Brand-Name Medications
If a generic is not available or appropriate, ask your doctor or healthcare provider to prescribe from your plan's preferred drug list. 25% ($25 minimum) 25%
Non-Preferred Brand-Name Medications (Includes Specialty Drug Formulary)
You will pay the most for medications not on your plan's preferred drug list. 40% ($40 minimum) 40%
Refill Limit None None
Annual Deductible $750 Individual DED RX ONLY $2,500 for an individual
$5,000 for a family
Out-of-Pocket Max $6,350 for an individual / $12,700 for a family (Combined with Medical)
CVS Caremark Retail Pharmacy Network
For short-term medications
(Up to a 31-day supply)
The CVS Caremark Retail Network includes more than 67,000 participating pharmacies nationwide, including independent pharmacies, chain pharmacies and 7,400 CVS Pharmacy locations. To locate a CVS Caremark participating retail network pharmacy in your area, simply click on "Find a Pharmacy" at www.caremark.com or call a Customer Care representative toll-free at (855) 465-0023.
CVS Caremark Mail Service Pharmacy or
CVS Caremark Retail-90 Pharmacy
For long-term medications
(Up to a 90-day supply)
You have the convenience of getting your long-term medications at one of our 51,000 Retail-90 Pharmacy locations for your mail service copay. Or simply mail your original prescription and the mail service order form to CVS Caremark. Your medications will be sent directly to your home, office or a location of your choice.
Web Services Register at www.caremark.com to access tools that can help you save money and manage your prescription benefit. To register, have your Prescription Card ready.
Customer Care Visit www.caremark.com or call at (855) 465-0023

Copayment, copay or coinsurance means the amount a plan participant is required to pay for a prescription in accordance with a Plan, which may be a deductible, a percentage of the prescription price, a fixed amount or other charge, with the balance, if any, paid by a Plan.

Prescription Benefit

This plan offers you choice and savings when it comes to filling long-term prescriptions. Now you have two ways to save. Plus, you can easily order refills and manage your prescriptions anytime at www.caremark.com.

CVS Caremark Mail Service Pharmacy

  • Enjoy convenient home delivery
  • Receive your medications in private, tamper-resistant and (when needed) temperature-controlled packaging
  • Talk to a pharmacist by phone

Retail-90 Pharmacy

  • Pick up your medication at a time that is convenient for you
  • Enjoy same-day prescription availability
  • Talk with a pharmacist face-to-face