A:  All GLP-1 are a Tier 2 Preferred Brand Copay of $40.

A: The answer yes, IF, the hospital is a contracted (Blue Cross) hospital. All in-network copays and deductibles apply towards the annual Out of Pocket Maximum. 

To meet the individual deductible in a plan year a member must meet the 50 copay cap ($35 x 50 = $1,750) as well as the Individual Deductible ($300).

A:   Examples of Office Visits to Specialty providers would include, but are not limited to:  Orthopedists, Gastroenterologists, Cardiologists, Endocrinologists, Neurologists, Oncologists, Urologists, Rheumatologists, Pulmonologists.

A:  Only Inpatient and Outpatient Hospital charges and charges from ambulatory surgical centers apply towards the annual deductible. Currently the annual Individual deductible is $300 and the annual Family deductible is $600 so only 2 members of a family need to meet their Individual to satisfy the Family deductible. Once the Family deductible is met, no other family members will have to satisfy a deductible for the rest of the plan year. The plan year runs from 9/1 – 8/31.

A:  Yes. There are other weight loss medications available on the CVS formulary that are far more cost effective which would allow a member to utilize them for years versus 3.5 months with a GLP-1.

A: With the Tier 3 Deducible option the member would need to satisfy a $300 deductible once per plan year before the plan would start paying for brand name prescriptions. Due to the high cost of brand name prescriptions this would most likely happen on the first brand name prescription filled in a plan year. Once the deductible is met, the member would then only pay the $50 copay for all remaining 30 day supplies of a brand name prescription for the rest of that plan year.  For example:

Member fills first brand name prescription in a plan year which costs $3,000:

• Member first pays the $300 Tier 3 Deductible as well as the $50 copay and the plan pays the remaining $2,650. 
• The Tier 3 Deductible is now met and the plan will pay 100% of the cost of all subsequent brand name fills after the member pays the $50 copay for the rest of the plan year. 
• The Plan year begins on 9/1 and ends on 8/31.

A:  An out of pocket maximum (OOPM) is the most you will pay during a plan year for in-network covered services. In-network copays and deductibles apply toward the OOPMs.

CUSD’s current 25/26 Plan Year OOPMs are as follows:

$2,050 - Individual

$4,100 – Family

To meet the individual deductible in a plan year a member must meet the 50 copay cap ($35 x 50 = $1,750) as well as the Individual Deductible ($300).

To meet the family OOPM 2 people in a family need to meet the Individual OOPM. Once the Family OOPM is met, no other family members have out of pocket expenses (copays or deductibles) for the rest of that plan year.