All cost-sharing assumes in-network healthcare providers.
Prescription Drug Copay/Coninsurance Details - Initial Coverage Limit
30 Day Supply | Preferred Retail Pharmacies Drug Cost | Standard Retail Pharmacies Drug Cost | Preferred Mail-Order Drug Cost | Standard Mail-Order Drug Cost |
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Tier 1: Preferred Generic | $0 copay | $5 copay | $0 copay | $5 copay |
Tier 2: Generic | $2 copay | $10 copay | $2 copay | $10 copay |
Tier 3: Preferred Brand | $47 copay | $47 copay | $47 copay | $47 copay |
Tier 4: Non-Preferred Drug | 50% coinsurance | 50% coinsurance | 50% coinsurance | 50% coinsurance |
Tier 5: Specialty Tier | 33% coinsurance | 33% coinsurance | 33% coinsurance | 33% coinsurance |
60 Day Supply | Preferred Retail Pharmacies Drug Cost | Standard Retail Pharmacies Drug Cost | Preferred Mail-Order Drug Cost | Standard Mail-Order Drug Cost |
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Tier 1: Preferred Generic | $0 copay | $10 copay | $0 copay | $10 copay |
Tier 2: Generic | $4 copay | $20 copay | $4 copay | $20 copay |
Tier 3: Preferred Brand | $94 copay | $94 copay | $94 copay | $94 copay |
Tier 4: Non-Preferred Drug | 50% coinsurance | 50% coinsurance | 50% coinsurance | 50% coinsurance |
Tier 5: Specialty Tier |
90 Day Supply | Preferred Retail Pharmacies Drug Cost | Standard Retail Pharmacies Drug Cost | Preferred Mail-Order Drug Cost | Standard Mail-Order Drug Cost |
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Tier 1: Preferred Generic | $0 copay | $15 copay | $0 copay | $15 copay |
Tier 2: Generic | $6 copay | $30 copay | $6 copay | $30 copay |
Tier 3: Preferred Brand | $141 copay | $141 copay | $141 copay | $141 copay |
Tier 4: Non-Preferred Drug | 50% coinsurance | 50% coinsurance | 50% coinsurance | 50% coinsurance |
Tier 5: Specialty Tier |