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| 30 Day Supply | Preferred Retail Pharmacies Drug Cost | Standard Retail Pharmacies Drug Cost | Preferred Mail-Order Drug Cost | Standard Mail-Order Drug Cost |
|---|---|---|---|---|
| Tier 1: Preferred Generic | $1 copay | $19 copay | $1 copay | $19 copay |
| Tier 2: Generic | $7 copay | $20 copay | $7 copay | $20 copay |
| Tier 3: Preferred Brand | $35 copay | $47 copay | $35 copay | $47 copay |
| Tier 4: Non-Preferred Drug | 35% coinsurance | 43% coinsurance | 35% coinsurance | 43% coinsurance |
| Tier 5: Specialty Tier | 25% coinsurance | 25% coinsurance | 25% coinsurance | 25% coinsurance |
| 60 Day Supply | Preferred Retail Pharmacies Drug Cost | Standard Retail Pharmacies Drug Cost | Preferred Mail-Order Drug Cost | Standard Mail-Order Drug Cost |
|---|---|---|---|---|
| Tier 1: Preferred Generic | $2 copay | $38 copay | $2 copay | $38 copay |
| Tier 2: Generic | $14 copay | $40 copay | $14 copay | $40 copay |
| Tier 3: Preferred Brand | $70 copay | $94 copay | $70 copay | $94 copay |
| Tier 4: Non-Preferred Drug | 35% coinsurance | 43% coinsurance | 35% coinsurance | 43% 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 |
|---|---|---|---|---|
| Tier 1: Preferred Generic | $3 copay | $57 copay | $0 copay | $57 copay |
| Tier 2: Generic | $21 copay | $60 copay | $7 copay | $20 copay |
| Tier 3: Preferred Brand | $105 copay | $141 copay | $87.5 copay | $117.5 copay |
| Tier 4: Non-Preferred Drug | 35% coinsurance | 43% coinsurance | 35% coinsurance | 43% coinsurance |
| Tier 5: Specialty Tier |