|
| |
| Plan Services Detail |
| Tier 1 |
|
Paid From |
Employee Out of Pocket |
| Retail Pharmacy |
Maintenance Account Only |
$100 |
|
| Tier 2 |
|
Paid From |
Employee Out of Pocket |
| Retail Pharmacy |
Spending Acct HRA Model |
$25 |
|
| Tier 3 |
|
Paid From |
Employee Out of Pocket |
| Retail Pharmacy |
Spending Acct HRA Model |
$50 |
|
| Out of tier
|
|
Paid From |
Employee Out of Pocket |
| Retail Pharmacy |
Ineligible |
% |
|
 |
|
|
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