City of Ithaca Plan Information

CLASS  Benefit Summary Summary of Benefits and Coverage Prescription Plan*
PBA Classic Blue 50/150 Classic Blue 50/150 RX $2/10/10 Retail or Mail
CSEA DPW Classic Blue 50/150 Classic Blue 50/150 RX $5/15/30 Retail $10/30/60 Mail
CSEA Admin Classic Blue 50/150 Classic Blue 50/150 RX $5/15/30 Retail $10/30/60 Mail
Confidential Classic Blue 50/150 Classic Blue 50/150 RX $5/15/30 Retail $10/30/60 Mail
Common Council Classic Blue 50/150 Classic Blue 50/150  RX $5/15/30 Retail $10/30/60 Mail
Managerial Classic Blue 50/150 Classic Blue 50/150 RX $5/15/30 Retail $10/30/60 Mail
PBA COBRA Classic Blue 50/150 Classic Blue 50/150 RX $2/10/10 Retail or Mail COBRA
CSEA DPW COBRA Classic Blue 50/150 Classic Blue 50/150 RX $5/15/30 Retail $10/30/60 Mail
CSEA Admin COBRA Classic Blue 50/150 Classic Blue 50/150 RX $5/15/30 Retail $10/30/60 Mail
Confidential COBRA Classic Blue 50/150 Classic Blue 50/150 RX $5/15/30 Retail $10/30/60 Mail
Managerial COBRA Classic Blue 50/150 Classic Blue 50/150 RX $2/10/10 Retail or Mail COBRA
Common Council COBRA Classic Blue 50/150 Classic Blue 50/150 RX $5/15/30 Retail $10/30/60 Mail COBRA 
Integrated Rx Retirees Classic Blue 50/150 Classic Blue 50/150 RX MM Rx Retirees
$1 Rx Retirees Classic Blue 50/150 Classic Blue 50/150  RX $1 Retirees
City Executive Assoc. Classic Blue 50/150 Classic Blue 50/150 RX $5/15/30 Retail $10/30/60 Mail
City Executive Assoc.  COBRA Classic Blue 50/150 Classic Blue 50/150  RX $5/15/30 Retail $10/30/60 Mail
IPFFA Classic Blue 50/150 Classic Blue 50/150 RX $5/15/30 Retail $10/30/60 Mail Retail 90 for 1 copay
COU Classic Blue 50/150 Classic Blue 50/150  RX $5/15/30 Retail $10/30/60 Mail Retail 90 for 1 copay
IPFFA COBRA Classic Blue 50/150 Classic Blue 50/150 RX $5/15/30 Retail $10/30/60 Mail COBRA Retail 90 for 1 copay 
COU COBRA Classic Blue 50/150 Classic Blue 50/150 RX $2/10/10 Retail or Mail COBRA
$2/5 Rx Retirees Classic Blue 50/150 Classic Blue 50/150 RX $2/5 Retirees
$2/10 Rx Retirees Classic Blue 50/150 Classic Blue 50/150 RX $2/10/10 Retail or Mail Retirees
$5/15/30 Rx Retirees Classic Blue 50/150 Classic Blue 50/150 RX $5/15/30 Retail  $10/30/60 Mail Order 
IPFFA Classic Blue 50/150 Classic Blue 50/150 RX $5/15/30 Retail $10/30/60 Mail Retail 90 for 1 copay
COU Classic Blue 50/150 Classic Blue 50/150  RX $5/15/30 Retail $10/30/60 Mail Retail 90 for 1 copay

*Prescription Plan is linked to Drug Formulary
* To view Participating Providers and your subscriber information please sign on to your Excellus account