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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 | Not offereds | $0 copay | $0 copay | $0 copay |
| Tier 2: Generic | Not offereds | $1 copay | $1 copay | $1 copay |
| Tier 3: Preferred Brand | Not offereds | 25% coinsurance | 25% coinsurance | 25% coinsurance |
| Tier 4: Non-Preferred Drug | Not offereds | 39% coinsurance | 39% coinsurance | 39% coinsurance |
| Tier 5: Specialty Tier | Not offereds | 25% coinsurance | 25% coinsurance | 25% coinsurance |
| 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 | Not offereds | $0 copay | $0 copay | $0 copay |
| Tier 2: Generic | Not offereds | $3 copay | $0 copay | $3 copay |
| Tier 3: Preferred Brand | Not offereds | 25% coinsurance | 15% coinsurance | 25% coinsurance |
| Tier 4: Non-Preferred Drug | Not offereds | 39% coinsurance | 30% coinsurance | 39% coinsurance |
| Tier 5: Specialty Tier |