2015 Active Premiums Copays

Plan Option

Health Assessment Credit & Non Tobacco User

Employee

Employee + Family

Anthem MCN

$55

(increase of $5)

$110

(increase of $10)

Anthem MEP

$55

(increase of $5)

$110

(increase of $10)

Anthem EPO

$82.50

(increase of $7.50)

$165

(increase of $15)

Aetna HMO

$77

(increase of $7)

$154

(increase of $14)

Keystone (PA)

$77

(increase of $7)

$154

(increase of $14)

Health America (PA)

$77

(increase of $7)

$154

(increase of $14)

Geisinger (PA)

$77

(increase of $7)

$154

(increase of $14)

Per the 2011-12 CBA, prescription co-pay increases are as follows:

In Network Retail

2014

2015

Generic

$8

$9

Single Source

(Brand Only)

30% of the DNP with a max of $25

30% of the DNP with a max of $26.50

Multi Source

(Brand w/Generic Avail)*

30% of the DNP with a max of $25

30% of the DNP with a max of $26.50

Mail Order

2014

2015

Generic

$16

$18

Single Source

(Brand Only)

30% of the DNP with a max of $50

30% of the DNP with a max of $53

Multi Source

(Brand w/Generic Avail)*

30% of the DNP with a max of $50

30% of the DNP with a max of $53

*NOTE: To receive the Brand drug when a generic is available at the lower copay, your doctor must contact ESI and explain the medical reason why you cannot take the generic (phone or complete form which is on the website); otherwise you will be responsible to pay an amount equal to the DNP, up to a maximum of $18, plus 100% of the cost difference between the brand name and the generic drug, and the fixed dollar maximum copays will not apply.