b'Blue Cross Blue Shield PPO Blue Cross Blue Shield HMO Illinois (HMOI)BEHAVIORAL HEALTH SERVICES BEHAVIORAL HEALTH SERVICESInpatient Inpatient90%PPO hospital $200deductible each hospital admission 50%Non-PPO hospital(not to exceed 2 copays per year)Outpatient Outpatient$10 Copay PPO provider$30Copay50%Non-PPO provider All care coordinated through your PCPPRESCRIPTION DRUG BENEFITS* PRESCRIPTION DRUG BENEFITS*Retail up to 30-Day Supply Retail up to 30-Day Supply$5Generic copay$10Generic copay$40 Formulary brand copay$30Formulary brand copay$75 Non-formulary brand copay$50 Non-formulary brand copay Retail up to 90-Day Supply Retail up to 90-Day Supply$15 Generic copay $25 Generic copay$120 Formulary brand copay $75 Formulary Brand copay$225 $125 Non-formulary brand copayNon-formulary brand copayMail Order up to 90-Day Supply Mail Order up to 90-Day Supply$10Generic copay $25 Generic copay$80Formulary brand copay $75 Formulary brand copay $150Non-formulary brand copay $125 Non-formulary brand copay * Specialty medications limited* Specialty medications limited to an up to 30-day supply to an up 30-day supply*Prescription Drug Plan ChangesEach health insurance plan utilizes a formulary (a list of preferred prescription drugs). INFO Formularies may change annually, so make sure you review your plans 2025formulary to determine if your prescription expenses will change. CTPF 2025 NON-MEDICARE HEALTH INSURANCE HANDBOOK CTPF 2025 NON-MEDICARE HEALTH INSURANCE HANDBOOK 15'