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Plan Rates
Effective January 1, 2007

PPO RATES SAGAMORE PLUS, ENCORE, CHA    
Trust Accounts Option #1 PLAN COBRA
N-167 - All Corporations PLAN TOTAL TOTAL
Single $533.00 $543.66
Family $1,300.00 $1,326.00
 
Trust Accounts Option #2 High Deductible    
All Corporations PLAN    
Single $491.00 $500.82
Family $1,223.00 $1247.46


ARNETT HMO 
Trust Accounts    PLAN COBRA 
Eastern Pulaski
Frontier
North White
Pioneer
Rossville
South Newton
Tri-County
Twin Lakes
West Central		 PLAN  TOTAL  TOTAL
Single $361.00 $368.22
Family $935.00 $953.70
 

Dental Rates
    PLAN COBRA
Account PLAN TOTAL TOTAL
N-167
Tri-County
Frontier		 Single $38.00  $38.76
Family $76.00 $77.52

RESTAT Prescription Drug Card Co-Pay

Retail Pharmay Prescriptions - 34 Day Supply
Brand Medication $25.00 or 20% whichever is greater
Generic Medication $10.00 or 20% whichever is greater
   
IPS Mail Orders: 3 Month Supply
90 day supply suggested for maintenance medications  
Brand Medication $50.00 or 20% whichever is greater
Generic Medication $20.00 or 20% whichever is greater
   
ARNETT HMO Prescription Drug Card CO-Pay - Participating Pharmacy  

Brand Name Drugs (Non Preferred Formulary)

$50.00

Brand Name Drugs (Preferred Formulary) 

$25.00

Generic Drugs

$10.00
ARNETT HMO Prescription Drug Card CO-Pay - Home Delivery (90 Day Supply)  

Brand Name Drugs (Non Preferred Formulary)

$150.00

Brand Name Drugs (Preferred Formulary) 

$50.00

Generic Drugs

$20.00

HMO ADVANTAGE HEALTH SOLUTIONS
Trust Accounts
PLAN
  
COBRA 
Eastern Pulaski
Plymouth
J.E.S.S.E.
John Glenn
New Prairie
Triton
Union North
South Central
Bremen
Single $361.00 $368.22
Family $975.00 $994.50
 

Advantage HMO Prescription Drug Card CO-Pay

Brand Name Drugs (Non Preferred Formulary)
$50.00
*Brand Name Drugs (Preferred Formulary) $25.00
Generic Drugs $10.00
Pharma Care Direct Mail Orders: 90 Day Supply

Brand Name Drugs (Non Preferred Formulary)

 $100.00
*Brand Name Drugs (Preferred Formulary) $50.00
Generic Drugs $20.00
*Note: Mandatory formulary generic when available or member pays the difference.