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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 | $5 copay | $1 copay | $5 copay |
| Tier 2: Generic | $4 copay | $10 copay | $4 copay | $10 copay |
| Tier 3: Preferred Brand | $42 copay | $47 copay | $42 copay | $47 copay |
| Tier 4: Non-Preferred Drug | 44% coinsurance | 50% coinsurance | 44% coinsurance | 50% coinsurance |
| Tier 5: Specialty Tier | 25% coinsurance | 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 | $3 copay | $15 copay | $0 copay | $15 copay |
| Tier 2: Generic | $12 copay | $30 copay | $0 copay | $30 copay |
| Tier 3: Preferred Brand | $126 copay | $141 copay | $116 copay | $141 copay |
| Tier 4: Non-Preferred Drug | 44% coinsurance | 50% coinsurance | 44% coinsurance | 50% coinsurance |
| Tier 5: Specialty Tier |