b'Blue Cross Blue Shield PPOBEHAVIORAL HEALTH SERVICESInpatient80%PPO hospital plus $200Plan Comparison: hospital admission deductibleNon-Medicare 50%Non-PPO hospital plus $400 hospital admissionEligible MembersdeductibleOutpatient80%PPO provider 50%Non-PPO providerPRESCRIPTION DRUG BENEFITS*Retail up to 30-Day Supply$10Generic copay$30Formulary brand copay$50Non-formulary brand copayRetail up to 90-Day Supply$25Generic copay$75Formulary brand copay$125 Non-formulary brand copayMail Order up to 90-Day Supply$20 Generic copay$60 Formulary brand copay$100 Non-formulary brand copay * Specialty medications limited to an up to 30-day supplyCTPF 2024 NON-MEDICARE HEALTH INSURANCE HANDBOOK CTPF 2024 NON-MEDICARE HEALTH INSURANCE HANDBOOK 17'