| CLASS | Benefit Summary | Summary of Benefits and Coverage | Prescription Plan* |
|---|---|---|---|
| Platinum Plan | Platinum Plan | RX $5/35/70 Retail or $10/70/140 Mail | |
| PBA | Classic Blue 50/150 (3T6) | Classic Blue 50/150 (3T6) | RX $5/15/30 Retail or $10/30/60 Mail |
| CSEA Admin | Classic Blue 50/150 (3T6) | Classic Blue 50/150 (3T6) | RX $5/15/30 Retail $10/30/60 Mail |
| City Executive Assoc. | Classic Blue 50/150 (3T6) | Classic Blue 50/150 (3T6) | RX $5/15/30 Retail or $10/30/60 Mail |
| Managerial | Classic Blue 50/150 (3T6) | Classic Blue 50/150 (3T6) | RX $5/15/30 Retail $10/30/60 Mail |
| IPFFA | Classic Blue 50/150 (3T5a) | Classic Blue 50/150 (3T5a) | RX $5/15/30 Retail/ Mail Retail 90 for 1 copay |
| COU | Classic Blue 50/150 (3T5a) | Classic Blue 50/150 (3T5a) | RX $5/15/30 Retail/ Mail Retail 90 for 1 copay |
| Retirees | |||
| $1 Rx Retirees | Classic Blue 50/150 (2T1) | Classic Blue 50/150 (2T1) | RX $1/1 Retail or Mail |
| $2/5 Rx Retirees | Classic Blue 50/150 (2T2) | Classic Blue 50/150 (2T2) | RX $2/5 Retail or Mail |
| $2/10 Rx Retirees | Classic Blue 50/150 (2T3) | Classic Blue 50/150 (2T3) | RX $2/10/10 Retail or Mail |
| $5/15/30 Rx Retirees | Classic Blue 50/150 (3T6) | Classic Blue 50/150 (3T6) | RX $5/15/30 Retail $10/30/60 Mail Order |
| IPFFA Retirees | Classic Blue 50/150 (3T5a) | Classic Blue 50/150 (3T5a) | RX $5/15/30 Retail/ Mail Retail 90 for 1 copay |
| COU Retirees | Classic Blue 50/150 (3T5a) | Classic Blue 50/150 (3T5a) | RX $5/15/30 Retail/ Mail Retail 90 for 1 copay |
| Platinum Retirees | Platinum Plan | Platinum Plan | RX $5/35/70 Retail or $10/70/140 Mail |
| Retirees | Medicare Supplement MS4 | RX $15/30/45 Retail $30/60/90 Mail Order |
*Prescription Plan is linked to Drug Formulary
* To view Participating Providers and your subscriber information please sign on to your Excellus account
