Virginia Plan Benefits
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Learn more about the HealthKeepers HDHP
Let’s break down some details for the HealthKeepers HDHP
- You can visit network or non-network providers.
- You don’t need a referral for in-network providers.
- Comes with a health savings account (HSA) to help you pay out-of-pocket expenses.
Pharmacy Benefits for HealthKeepers HDHP
Prescription Drug Copays for 2022
Level 1 |
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|---|---|---|---|---|
| 30-Day Supply (Retail) | Yearly Cost 30-Day Supply (Retail) | 90-day Supply (Mail Order) | Yearly Cost 90-Day Supply (Mail Order) | |
| Tier 1 | $10 copay after calendar year deductible | $120.00 | $25 copay after calendar year deductible | $100.00 |
| Tier 2 | $40 copay after calendar year deductible | $480.00 | $100 copay after calendar year deductible | $400.00 |
| Tier 3 | $70 copay after calendar year deductible | $840.00 | $175 copay after calendar year deductible | $700.00 |
| Tier 4 |
25% of our allowance after calendar year deductible
($300 maximum per prescription) |
— | 90-day supply is not available | 90-day supply is not available |
Prescription Drug Copays for 2022 at Level Two - HealthKeepers HDHP
Level 2 |
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|---|---|---|---|---|
| 30-Day Supply (Retail) | Yearly Cost 30-Day Supply (Retail) | 90-day Supply (Mail Order) | Yearly Cost 90-Day Supply (Mail Order) | |
| Tier 1 | $20 copay after calendar year deductible | $240.00 | $25 copay after calendar year deductible | $100.00 |
| Tier 2 | $50 copay after calendar year deductible | $600.00 | $100 copay after calendar year deductible | $400.00 |
| Tier 3 | $80 copay after calendar year deductible | $960.00 | $175 copay after calendar year deductible | $700.00 |
| Tier 4 |
25% of our allowance after calendar year deductible
($300 maximum per prescription) |
— | 90-day supply is not available | 90-day supply is not available |
On the next page, choose Essentials Tier-4
