Medical

You may consider the...

• HD Value Plan if you are generally healthy and expect to have low medical plan usage except for annual checkups and occasional illnesses. You will pay lower premiums than the other two plans but will pay more out-of-pocket when you use the plan benefits.
• HD Standard Plan if you expect to have moderate medical expenses. With the Standard Plan, you will pay higher premiums than the HD Value Plan, but your out-of-pocket costs will be lower when you use the plan benefits. You will also have a lower deductible and out-of-pocket maximum.
• PPO Plan if you expect to have high medical plan usage, and want to rely on a lower out-of-pocket maximum. The PPO Plan has the highest monthly premiums in exchange for paying lower out-of-pocket costs. It also has the lowest deductible of all three plans.

Compare here! Use the Medical Plan Cost Estimator to see your health costs under each medical plan option.

True family deductible: The HD Value Plan and HD Standard Plan both have a true family deductible. This means that the combined total of your covered family members’ eligible expenses is used to reach the family deductible, before coinsurance begins.

Embedded out-of-pocket maximum: The HD Value Plan and HD Standard Plan both have an embedded out-of-pocket maximum. This means that if one covered family member reaches the single out-of-pocket maximum, eligible claims for the rest of the year for that individual will be paid by the plan in full. The feature works for every covered family member until the family out-of-pocket maximum is met. Then the plan pays 100% of eligible expenses for the entire family.

Coverage for preventive prescriptions: Certain preventive prescriptions are covered at the levels below with no deductible requirement. These drugs are on the CDH Preventive Medicine List and the formulary drug list.

• HD Value Plan: Plan pays 70%; you pay 30%.
• HD Standard Plan: Plan pays 80%; you pay 20%.

Certain prescription contraceptives for women are covered at 100% with no deductible as well.

Express Scripts uses a preferred drug list, called a formulary, which includes both generic and preferred brand-name drugs. Your cost for a specific prescription drug is based on which type of medicine you and your doctor choose. We recommend that you check the formulary list before you fill any prescriptions. Keep in mind, prescription drug prices and categories can change throughout the year and will be reflected when a change occurs.

These plans comply with Affordable Care Act (ACA) requirements to cover certain preventive items and services at a zero dollar cost share to their members.

Embedded deductible and out-of-pocket maximum: The PPO Plan has an embedded deductible and out-of-pocket maximum. This means that if one covered family member reaches the single deductible, coinsurance will begin for that individual. This feature works for every covered family member until the family deductible is met. The out-of-pocket maximum works the same way – when one of your covered family members reaches the single out-of-pocket maximum, eligible claims for the rest of the year for that individual will be paid by the plan in full. The feature works for every covered family member until the family out-of-pocket maximum is met. Then the plan pays 100% of eligible expenses for the entire family.

Formulary: A formulary is a preferred drug list that includes generic and preferred brand-name drugs. If you enroll in the HD Value Plan, HD Standard Plan or PPO Plan and receive your prescription coverage through Express Scripts, your cost for a specific prescription drug is based on the type of medicine you and your doctor choose. It’s important that you discuss your medication needs and options with your doctor to ensure you’re getting what you need at the lowest cost.

H&R Block recommends that you check the formulary list before you fill any prescriptions. Prescription drug prices and categories can change throughout the year and will be reflected as such when a change occurs.

Long-term maintenance medications: You can choose how you want to fill your long-term maintenance medications. You can either have a 90-day supply of your medication sent to your home through mail order, or you can pick up a 30-day supply of your medication at your retail pharmacy.

If you choose home delivery for 90-day refills, you’ll pay the lowest price for your medication through deeper discounts. On average, you save about 25% on costs when you fill long-term prescriptions through mail order versus a retail pharmacy. You will not be able to fill a 90-day prescription at a retail pharmacy; only 30-day supplies can be purchased at a retail pharmacy.

You can fill a 30-day prescription for a long-term maintenance drug twice at a retail pharmacy, covered by the plan with the standard coinsurance or co-pay. After two retail pharmacy fills, if you don’t switch to home delivery, you will pay full price.

Generic medications: You are encouraged to use generic medications as an effective cost-saving step. If a generic equivalent medication is available and you choose a brand-name drug instead, you will pay the cost for the brand-name drug, but only the cost for the generic equivalent will apply toward your deductible. This penalty will not apply if your physician requests a brand-name drug and writes “dispense as written” on your prescription.

Prior authorization: Certain medications may require approval from Express Scripts to be covered by your medical plan. Your doctor will make a recommendation that will have to be approved by Express Scripts. The list of medications subject to prior authorization is reviewed and updated each year. Learn more here.

Step therapy: Step therapy is a process by which a lower-priced medication that is effective to meet your care and financial needs is recommended before stepping up to one that costs more. Here’s an example of step therapy. Let’s say you have allergies. You should first try using an over-the-counter medication. If that doesn’t help you, you’re encouraged to try a tier 1 medication, which is less expensive than tier 2 or tier 3 medication. If that doesn’t work, we’ll review if you met the step therapy requirements before your plan will help pay for a tier 2 or tier 3 medication. Review the list of medical conditions that require step therapy. Learn more here.

Formulary: A formulary is a preferred drug list that includes generic and preferred brand-name drugs. If you enroll in the Kaiser HMO and receive your prescription coverage through Kaiser Permanente, your cost for a specific prescription drug is based on the type of medicine you and your doctor choose.

H&R Block recommends that you check the formulary list before you fill any prescriptions. Even though nonformulary drugs are generally not covered under your prescription drug plan, your Kaiser Permanente physician can sometimes request a nonformulary drug for you, specifically when formulary alternatives have failed or use of nonformulary drug is medically necessary, provided the drug is not excluded by your plan.

H&R Block recommends that you check the formulary list before you fill any prescriptions. Prescription drug prices and categories can change throughout the year and will be reflected as such when a change occurs.

Generic medications: You are encouraged to use generic medications as an effective cost-saving step. If you want a brand-name or specialty drug for which there is a generic equivalent, or if you request a nonformulary drug, you will pay 100% of the charges since they are not covered.

Well Rx Program: The Well Rx Program is a program that provides members who meet specific eligibility criteria with certain chronic disease drugs or diabetes supplies without charge.