Office of Group Insurance
Department of Administration

Employee Group Insurance Benefits

Prescription Drug Plan Snapshot

Your prescription drug coverage is included in your medical coverage choice.

For details about the prescription drug plan, including copayment explanations, exclusions, limitations, and how the plan works, please see the Benefits Summary & Plan Contracts.

	Traditional		PPO		High-Deductible
	IN	OUT	IN	OUT	IN	OUT
Tier 1: Generic	$10		$10		$10
Tier 2: Formulary Brand Name	$25		$25		$25
Tier 3: Non-Formulary Brand Name	$50		$50		$50
Documents	Benefits Summary Plan Contract		Benefits Summary Plan Contract		Benefits Summary Plan Contract

QUESTIONS?

Phone:
Fax:
Email:

(208) 332-1860 or (800) 531-0597
(208) 332-1888
ogi@adm.idaho.gov