For coverage becoming effective on or after January 1, 2010

5-tier drug riders

For large and small groups

• 2/5/15/20/40
• 2/7/15/35/70
• 2/7/20/40/80
• 2/10/25/45/90
• 2/15/30/50/100
• 2/15/50/150
• 2/15/50/150-5000
• 250/50
• 5-tier drug list

3-tier drug riders

For state-mandated plans only

• 10/30/50
• 10/50/100
• 30 (diabetic medication and supplies only)
• 3-tier drug list

Health benefit plans offered by Health First Health Plans, Inc. (HFHP) may be subject to limitations and exclusions. For costs and complete details, contact your employer, insurance agent, or HFHP.
2/16/2012

www-rx10(3/2012)