Silver Level 2015 Coverage *Based on your income, you might qualify for cost- Tier 1 (preferred generic)- copay $15, no deductible sharing. If you are Tier 2 (preferred brand)- co-pay interested, please ask for $45 once deductible ($500) paid more information or call the insurance plan! Tier 3 (non-preferred brand)- co- Aetna Silver $10 Copay OAMC These are the HIV/AIDS medications that this plan covers. The generic names are in bold. The pyramid at the top shows the different cost tiers. This means that the medications are put into groups that have different costs to you. This list is only an example of what your medications might cost at a retail price, but the specific cost for you might be different. No medications in Tiers 1, 2, and 3 for this plan pay $75 once deductible ($500) paidspecialty)- coTier 4 (preferred insurance 40% once deductible ($500) paid specialty)- coTier 5 (non-preferred insurance 50% once deductible ($500) paid *If not in network, specialty meds not covered. Tier 4 abacavir Tier 5 Atripla abacavir-lamivudine-zidovudine Aptivus Didanosine Crixivan lamivudine Combivir lamivudine-zidovudine Complera Nevirapine Edurant stavudine Emtriva Tivicay Epivir Trizivir Epzicom zidovudine Fuzeon Intelence Invirase Isentress Write down the medications you are on and what tier they are in! Atripla/Tier 5  (Example)  _________________________________  _________________________________  _________________________________  _________________________________ For information and specific costs, please call the insurance plan or 215-977-7255 to speak with an insurance navigator! Kaletra Lexiva nevirapine er Norvir Prezista Rescriptor Reyataz Selzentry Stribild Sustiva Truvada Videx Viracept Viramune Viread Ziagen Silver Level 2015 Coverage *Based on your income, you Tier 1 (preferred generic)- comight qualify for costpay $15, no deductible sharing. If you are Tier 2 (preferred brand)- co-pay interested, please ask for $45 once deductible ($500) paid more information or call the Tier 3 (non-preferred brand)- coinsurance plan! Aetna Silver $10 Copay HMO These are the HIV/AIDS medications that this plan covers. The generic names are in bold. The pyramid at the top shows the different cost tiers. This means that the medications are put into groups that have different costs to you. This list is only an example of what your medications might cost at a retail price, but the specific cost for you might be different. No medications in Tiers 1, 2, and 3 for this plan pay $75 once deductible ($500) paidspecialty)- coTier 4 (preferred insurance 40% once deductible ($500) paid specialty)- coTier 5 (non-preferred insurance 50% once deductible ($500) paid *If not in network, not covered. Tier 4 Abacavir Tier 5 Atripla abacavir-lamivudine-zidovudine Aptivus Didanosine Crixivan Lamivudine Combivir lamivudine-zidovudine Complera Nevirapine Edurant Stavudine Emtriva Tivicay Epivir Trizivir Epzicom Zidovudine Fuzeon Intelence Invirase Write down the medications you are on and what tier they are in! Atripla/Tier 5 Isentress Kaletra Lexiva  (Example)  _________________________________  _________________________________  _________________________________ Rescriptor  _________________________________ Reyataz For information and specific costs, please call the insurance plan or 215-977-7255 to speak with an insurance navigator! nevirapine er Norvir Prezista Selzentry Stribild Sustiva Truvada Videx Viracept Viramune Viread Ziagen Silver Level 2015 Coverage *Based on your income, you Tier 1 (preferred generic)- comight qualify for costpay $15, no deductible sharing. If you are Tier 2 (preferred brand)- co-pay interested, please ask for $40 once deductible ($500) paid more information or call the Tier 3 (non-preferred brand)- coinsurance plan! Aetna Silver $10 Copay HMO Savings Plus These are the HIV/AIDS medications that this plan covers. The generic names are in bold. The pyramid at the top shows the different cost tiers. This means that the medications are put into groups that have different costs to you. This list is only an example of what your medications might cost at a retail price, but the specific cost for you might be different. No medications in Tiers 1, 2, and 3 for this plan pay $70 once deductible ($500) paidspecialty)- coTier 4 (preferred insurance 40% once deductible ($500) paid specialty)- coTier 5 (non-preferred insurance 50% once deductible ($500) paid *If not in network, not covered. Tier 4 Abacavir Tier 5 Atripla abacavir-lamivudine-zidovudine Aptivus Didanosine Crixivan Lamivudine Combivir lamivudine-zidovudine Complera Nevirapine Edurant Stavudine Emtriva Tivicay Epivir Trizivir Epzicom Zidovudine Fuzeon Write down the medications you are on and what tier they are in! Atripla/Tier 5 Intelence Invirase Isentress Kaletra  (Example)  _________________________________ nevirapine er  _________________________________ Norvir  _________________________________ Prezista  _________________________________ For information and specific costs, please call the insurance plan or 215-977-7255 to speak with an insurance navigator! Lexiva Rescriptor Reyataz Selzentry Stribild Sustiva Truvada Videx Viracept Viramune Viread Ziagen Silver Level 2015 Coverage *Based on your income, you Tier 1 (preferred generic)- comight qualify for costpay $15, no deductible sharing. If you are Tier 2 (preferred brand)- co-pay interested, please ask for $40 once deductible ($2500) paid more information or call the Tier 3 (non-preferred brand)- coinsurance plan! Aetna Silver $5 Copay 2500 HMO Savings Plus These are the HIV/AIDS medications that this plan covers. The generic names are in bold. The pyramid at the top shows the different cost tiers. This means that the medications are put into groups that have different costs to you. This list is only an example of what your medications might cost at a retail price, but the specific cost for you might be different. No medications in Tiers 1, 2, and 3 for this plan pay $75 once deductible ($2500) paidspecialty)- coTier 4 (preferred insurance 40% once deductible ($2500) paid specialty)- coTier 5 (non-preferred insurance 50% once deductible ($2500) *If not in network, not covered. paid Tier 4 Abacavir Tier 5 Atripla abacavir-lamivudine-zidovudine Aptivus Didanosine Crixivan Lamivudine Combivir lamivudine-zidovudine Complera Nevirapine Edurant Stavudine Emtriva Tivicay Epivir Trizivir Epzicom Zidovudine Fuzeon Write down the medications you are on and what tier they are in! Atripla/Tier 5 Intelence Invirase Isentress Kaletra  (Example)  _________________________________ nevirapine er  _________________________________ Norvir  _________________________________ Prezista  _________________________________ For information and specific costs, please call the insurance plan or 215-977-7255 to speak with an insurance navigator! Lexiva Rescriptor Reyataz Selzentry Stribild Sustiva Truvada Videx Viracept Viramune Viread Ziagen Silver Level 2015 Coverage *Based on your income, you might qualify for cost- Tier 1 (preferred generic)- cosharing. If you are pay $15, no deductible interested, please ask for Tier 2 (preferred brand)- co-pay more information or call the $45 once deductible ($2750) paid insurance plan! Tier 3 (non-preferred brand)- co- Aetna Silver $5 Copay 2750 HMO These are the HIV/AIDS medications that this plan covers. The generic names are in bold. The pyramid at the top shows the different cost tiers. This means that the medications are put into groups that have different costs to you. This list is only an example of what your medications might cost at a retail price, but the specific cost for you might be different. No medications in Tiers 1, 2, and 3 for this plan pay $75 once deductible ($2750) paidspecialty)- coTier 4 (preferred insurance 40% once deductible ($2750) paid specialty)- coTier 5 (non-preferred insurance 50% once deductible ($2750) *If not in network, not covered. paid Tier 4 Abacavir Tier 5 Atripla abacavir-lamivudine-zidovudine Aptivus Didanosine Crixivan Lamivudine Combivir lamivudine-zidovudine Complera Nevirapine Edurant Stavudine Emtriva Tivicay Epivir Trizivir Epzicom Zidovudine Fuzeon Intelence Invirase Write down the medications you are on and what tier they are in! Atripla/Tier 5  (Example)  _________________________________  _________________________________  _________________________________  _________________________________ For information and specific costs, please call the insurance plan or 215-977-7255 to speak with an insurance navigator! Isentress Kaletra Lexiva nevirapine er Norvir Prezista Rescriptor Reyataz Selzentry Stribild Sustiva Truvada Videx Viracept Viramune Viread Ziagen Silver Level *Based on your income, you might qualify for costsharing. If you are interested, please ask for more information or call the insurance plan! 2015 Coverage Aetna Silver $5 Copay 2750 OAMC These are the HIV/AIDS medications that this plan covers. The generic names are in bold. The pyramid at the top shows the different cost tiers. This means that the medications are put into groups that have different costs to you. This list is only an example of what your medications might cost at a retail price, but the specific cost for you might be different. No medications in Tiers 1, 2, and 3 for this plan Tier 1 (preferred generic)- copay $15, no deductible Tier 2 (preferred brand)- co-pay $45 once deductible ($2750) paid Tier 3 (non-preferred brand)- copay $75 once deductible ($2750) paidspecialty)- coTier 4 (preferred insurance 40% once deductible ($2750) paid specialty)- coTier 5 (non-preferred insurance 50% once deductible ($2750) *If not in network, specialty paid meds not covered. Tier 4 Abacavir Tier 5 Atripla abacavir-lamivudine-zidovudine Aptivus Didanosine Crixivan Lamivudine Combivir lamivudine-zidovudine Complera Nevirapine Edurant Stavudine Emtriva Tivicay Epivir Trizivir Epzicom Zidovudine Fuzeon Intelence Invirase Write down the medications you are on and what tier they are in! Atripla/Tier 5  (Example)  _________________________________  _________________________________  _________________________________  _________________________________ For information and specific costs, please call the insurance plan or 215-977-7255 to speak with an insurance navigator! Isentress Kaletra Lexiva nevirapine er Norvir Prezista Rescriptor Reyataz Selzentry Stribild Sustiva Truvada Videx Viracept Viramune Viread Ziagen Silver Level 2015 Coverage * Cost-sharing reductions available! If you are interested, please ask for more information or call the insurance plan! IBC Keystone HMO Silver These are the HIV/AIDS medications that this plan covers. The generic names are in bold. The pyramid at the top shows the different cost tiers. This means that the medications are put into groups that have different costs to you. This list is only an example of what your medications might cost at a retail price, but the specific cost for you might be different. Tier 1 (preferred generic)- copay $4 (no HIV/AIDs drugs) Tier 2 (generic)- co-pay $15 Tier 3 (preferred brand)- coinsurance 40% not to exceed $300 for each medication Tier 4 (non-formulary/nonpreferred)- co-insurance 50% not to exceed $300 for each medication *If not in network, 70% co-insurance Tier 1 Tier 2 Tier 3 Tier 4 abacavir Atripla Aptivus abacavir-lamivudinezidovudine Complera Combivir (generic lamivudine-zidovudine- Tier 2) didanosine Crixivan Epivir (generic lamivudine- Tier 2) lamivudine Edurant Intelence lamivudinezidovudine Emtriva Rescriptor nevirapine/nevirapine Epzicom er Retrovir (generic zidovudine- Tier 2) stavudine Fuzeon Tivicay zidovudine Invirase Trizivir (generic abacavir-lamivudine-zidovudine- Tier 2) Isentress Triumeq Kaletra Videx Ec (generic didanosine- Tier 2) Lexiva Videx Pediatric (generic didanosine- Tier 2) Norvir Viramune (generic nevirapine-Tier 2) Prezista Zerit (generic stavudine- Tier 2) Reyataz Ziagen (generic abacavir- Tier 2) Selzentry Stribild Sustiva Truvada Viracept Viramune Xr 100mg (generic nevirapineTier 2) Viread Write down the medications you are on and what tier they are in! Atripla/Tier 3  (Example)  _________________________________  _________________________________  _________________________________  _________________________________ For information and specific costs, please call the insurance plan or 215-977-7255 to speak with an insurance navigator! Silver Level 2015 Coverage * Cost-sharing reductions available! If you are interested, please ask for more information or call the insurance plan! Tier 1 (preferred generic)- copay $4 (no HIV/AIDs drugs) Tier 2 (generic)- co-pay $15 Tier 3 (preferred brand)- coinsurance 50% not to exceed $400 for each medication IBC Keystone HMO Silver Proactive These are the HIV/AIDS medications that this plan covers. The generic names are in bold. The pyramid at the top shows the different cost tiers. This means that the medications are put into groups that have different costs to you. This list is only an example of what your medications might cost at a retail price, but the specific cost for you might be different. Tier 1 Tier 2 Tier 3 Tier 4 (non-formulary/nonpreferred)- co-insurance 50% not to exceed $500 for each medication *If not in network, 70% co-insurance Tier 4 abacavir Atripla Aptivus abacavir-lamivudinezidovudine Complera Combivir (generic lamivudine-zidovudine- Tier 2) didanosine Crixivan Epivir (generic lamivudine- Tier 2) lamivudine Edurant Intelence lamivudinezidovudine Emtriva Rescriptor nevirapine/nevirapine Epzicom er Retrovir (generic zidovudine- Tier 2) stavudine Fuzeon Tivicay zidovudine Invirase Trizivir (generic abacavir-lamivudine-zidovudine- Tier 2) Isentress Triumeq Kaletra Videx Ec (generic didanosine- Tier 2) Lexiva Videx Pediatric (generic didanosine- Tier 2) Norvir Viramune (generic nevirapine-Tier 2) Prezista Zerit (generic stavudine- Tier 2) Reyataz Ziagen (generic abacavir- Tier 2) Selzentry Stribild Sustiva Truvada Viracept Viramune Xr 100mg (generic nevirapineTier 2) Viread Write down the medications you are on and what tier they are in! Atripla/Tier 3  (Example)  _________________________________  _________________________________  _________________________________  _________________________________ For information and specific costs, please call the insurance plan or 215-977-7255 to speak with an insurance navigator! Silver Level 2015 Coverage * Cost-sharing reductions available! If you are interested, please ask for more information or call the insurance plan! These are the HIV/AIDS medications that this plan covers. The generic names are in bold. The pyramid at the top shows the different cost tiers. This means that the medications are put into groups that have different costs to you. This list is only an example of what your medications might cost at a retail price, but the specific cost for you might be different. Tier 2 Tier 3 Tier 2 (generic)- co-pay $15 Tier 3 (preferred brand)- coinsurance 30% not to exceed $200 for each medication IBC Personal Choice PPO Silver Tier 1 Tier 1 (preferred generic)- copay $4 (no HIV/AIDs drugs) Tier 4 (non-formulary/nonpreferred)- co-insurance 40% not to exceed $200 for each medication *If not in network, 70% co-insurance Tier 4 abacavir Atripla Aptivus abacavir-lamivudinezidovudine Complera Combivir (generic lamivudine-zidovudine- Tier 2) didanosine Crixivan Epivir (generic lamivudine- Tier 2) lamivudine Edurant Intelence lamivudinezidovudine Emtriva Rescriptor nevirapine/nevirapine Epzicom er Retrovir (generic zidovudine- Tier 2) stavudine Fuzeon Tivicay zidovudine Invirase Trizivir (generic abacavir-lamivudine-zidovudine- Tier 2) Isentress Triumeq Kaletra Videx Ec (generic didanosine- Tier 2) Lexiva Videx Pediatric (generic didanosine- Tier 2) Norvir Viramune (generic nevirapine-Tier 2) Prezista Zerit (generic stavudine- Tier 2) Reyataz Ziagen (generic abacavir- Tier 2) Selzentry Stribild Sustiva Write down the medications you are on and what tier they are in! Atripla/Tier 3 Truvada  (Example) Viracept  _________________________________ Viramune Xr 100mg (generic nevirapineTier 2)  _________________________________  _________________________________ Viread  _________________________________ For information and specific costs, please call the insurance plan or 215-977-7255 to speak with an insurance navigator! Silver Level 2015 Coverage *Based on your income, you might qualify for costsharing. If you are interested, please ask for more information or call the insurance plan! Tier 1 (preferred generic)- copay $4 (no HIV/AIDS drugs) Tier 2 (generic)- co-pay $15 Tier 3 (preferred brand)- coinsurance 30% not to exceed $200 IBC Blue Cross Silver, a Multi-State Plan These are the HIV/AIDS medications that this plan covers. The generic names are in bold. The pyramid at the top shows the different cost tiers. This means that the medications are put into groups that have different costs to you. This list is only an example of what your medications might cost at a retail price, but the specific cost for you might be different. Tier 1 Tier 2 Tier 3 Tier 4 (non-formulary/nonpreferred)- co-insurance 40% not to exceed $200 *If not in network, 70% co-insurance Tier 4 abacavir Atripla Aptivus abacavir-lamivudinezidovudine Complera Combivir (generic lamivudine-zidovudine- Tier 2) didanosine Crixivan Epivir (generic lamivudine- Tier 2) lamivudine Edurant Intelence lamivudinezidovudine Emtriva Rescriptor nevirapine/nevirapine Epzicom er Retrovir (generic zidovudine- Tier 2) stavudine Fuzeon Tivicay zidovudine Invirase Trizivir (generic abacavir-lamivudine-zidovudine- Tier 2) Isentress Triumeq Kaletra Videx Ec (generic didanosine- Tier 2) Lexiva Videx Pediatric (generic didanosine- Tier 2) Norvir Viramune (generic nevirapine-Tier 2) Prezista Zerit (generic stavudine- Tier 2) Reyataz Ziagen (generic abacavir- Tier 2) Selzentry Stribild Write down the medications you are on and what tier they are in! Sustiva  (Example) Truvada  _________________________________  _________________________________  _________________________________  _________________________________ Viracept Viramune Xr 100mg (generic nevirapineTier 2) Viread Atripla/Tier 3 For information and specific costs, please call the insurance plan or 215-977-7255 to speak with an insurance navigator! Silver Level Tier 1 - co-pay $5, no deductible Tier 2 - co-pay $50, no deductible 2015 Coverage Tier 3 - co-insurance 20% with $150 co-pay min. and $1000 deductible UnitedHealthcare Silver Compass 5000 Tier 4 - co-insurance 30% with $300 co-pay min. and $1000 deductible These are the HIV/AIDS medications that this plan covers. The generic names are in bold. The pyramid at the top shows the different cost tiers. This means that the medications are put into groups that have different costs to you. This list is only an example of what your medications might cost at a retail price, but the specific cost for you might be different. Tier 1 Tier 2 *If not in network, not covered. Tier 3 Tier 4 abacavir Aptivus (cap) Aptivus (sol) abacavir-lamivudinezidovudine Atripla Triumeq didanosine Complera Epivir (generic lamivudine- Tier 1) lamivudine Crixivan Retrovir (generic zidovudine- Tier 1) lamivudine-zidovudine Edurant Stribild nevirapine/nevirapine er Emtriva Tivicay stavudine Epzicom Trizivir (generic abacavir-lamivudinezidovudine- Tier 1) zidovudine Fuzeon Videx Ec (generic didanosine- Tier 1) Intelence Viramune (generic nevirapine-Tier 1) Invirase Zerit (generic stavudine- Tier 1) Isentress Ziagen (generic abacavir- Tier 1) aletra Lexiva Norvir Combivir (generic lamivudinezidovudine- Tier 1) Write down the medications you are on and what tier they are in! Atripla/Tier 2 Prezista  (Example) Rescriptor  _________________________________ Reyataz  _________________________________ Selzentry  _________________________________  _________________________________ Sustiva Truvada Videx Pediatric (generic didanosine- Tier 1) Viracept Viramune Xr 100mg (generic nevirapine-Tier 1) Viread For information and specific costs, please call the insurance plan or 215-977-7255 to speak with an insurance navigator! Silver Level Tier 1 - co-pay $10, $1600 deductible Tier 2 - co-pay $50, $1600 deductible 2015 Coverage UnitedHealthcare Silver Compass HSA 1600 Tier 3 - co-insurance 20% with $150 co-pay min., $1600 deductible These are the HIV/AIDS medications that this plan covers. The generic names are in bold. The pyramid at the top shows the different cost tiers. This means that the medications are put into groups that have different costs to you. This list is only an example of what your medications might cost at a retail price, but the specific cost for you might be different. Tier 1 Tier 2 Tier 4 - co-insurance 30% with $300 co-pay min., $1600 deductible *If not in network, not covered. Tier 3 Tier 4 abacavir Aptivus (cap) Aptivus (sol) abacavir-lamivudinezidovudine Atripla Triumeq didanosine Complera Epivir (generic lamivudine- Tier 1) lamivudine Crixivan Retrovir (generic zidovudine- Tier 1) lamivudine-zidovudine Edurant Stribild nevirapine/nevirapine er Emtriva Tivicay stavudine Epzicom Trizivir (generic abacavir-lamivudinezidovudine- Tier 1) zidovudine Fuzeon Videx Ec (generic didanosine- Tier 1) Intelence Viramune (generic nevirapine-Tier 1) Invirase Zerit (generic stavudine- Tier 1) Isentress Ziagen (generic abacavir- Tier 1) aletra Lexiva Norvir Combivir (generic lamivudinezidovudine- Tier 1) Write down the medications you are on and what tier they are in! Atripla/Tier 2 Prezista  (Example) Rescriptor  _________________________________ Reyataz  _________________________________ Selzentry  _________________________________  _________________________________ Sustiva Truvada Videx Pediatric (generic didanosine- Tier 1) Viracept Viramune Xr 100mg (generic nevirapine-Tier 1) Viread For information and specific costs, please call the insurance plan or 215-977-7255 to speak with an insurance navigator! Silver Level Tier 1 (generic) – no charge after deductible of $3500 2015 Coverage Tier 2 (preferred brand) – no charge after deductible of $3500 Assurant Health Silver Plan 001 These are the HIV/AIDS medications that this plan covers. The generic names are in bold. The pyramid at the top shows the different cost tiers. This means that the medications are put into groups that have different costs to you. This list is only an example of what your medications might cost at a retail price, but the specific cost for you might be different. Tier 1 Abacavir Tier 2 Atripla Didanosine Aptivus Lamivudine Crixivan lamivudine-zidovudine Combivir Nevirapine Complera Stavudine Edurant Zidovudine Emtriva Epivir *Same rates apply if not in network. Injectable Medicine May be Covered Under the Medical Benefit Fuzeon Epzicom Tivicay Intelence Invirase Isentress Kaletra Lexiva Norvir Prezista Rescriptor Write down the medications you are on and what tier they are in! Atripla/Tier 2 Retrovir  (Example) Reyataz  _________________________________  _________________________________  _________________________________  _________________________________ Selzentry Stribild Sustiva Triumeq Truvada Videx Viracept Viramune Viread Zerit Ziagen For information and specific costs, please call the insurance plan or 215-977-7255 to speak with an insurance navigator! Silver Level Tier 1 (generic) – co-pay $15 2015 Coverage Tier 2 (preferred brand) – copay $35 Assurant Health Silver Plan 002 Tier 3 (non-preferred brand) – co-pay $60 These are the HIV/AIDS medications that this plan covers. The generic names are in bold. The pyramid at the top shows the different cost tiers. This means that the medications are put into groups that have different costs to you. This list is only an example of what your medications might cost at a retail price, but the specific cost for you might be different Tier 1 Tier 2 Tier 3 *Same rates apply if not in network. Injectable Medicine May be Covered Under the Medical Benefit abacavir Aptivus Atripla didanosine Emtriva Crixivan lamivudine Kaletra Combivir (generic lamivudinezidovudine- Tier 1) lamivudinezidovudine Lexiva Complera nevirapine Norvir Edurant stavudine Prezista Epivir (generic lamivudine- Tier 1) zidovudine Reyataz Epzicom Sustiva Isentress Truvada Intelence Videx (solution) Invirase  (Example) Viread Rescriptor  ____________________  ____________________  ____________________  ____________________ Retrovir (generic zidovudine- Tier 1) Selzentry Stribild Tivicay Triumeq Videx Ec (generic didanosine- Tier 1) Viracept Viramune (generic nevirapine-Tier 1) Zerit (generic stavudine- Tier 1) Ziagen (generic abacavir- Tier 1) Fuzeon Write down the medications you are on and what tier they are in! Atripla/Tier 3 For information and specific costs, please call the insurance plan or 215977-7255 to speak with an insurance navigator!