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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 | $0 copay | $3 copay | $0 copay | $3 copay |
| Tier 2: Generic | $3 copay | $6 copay | $3 copay | $6 copay |
| Tier 3: Preferred Brand | $34 copay | $45 copay | $34 copay | $45 copay |
| Tier 4: Non-Preferred Drug | 34% coinsurance | 45% coinsurance | 34% coinsurance | 45% 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 | $0 copay | $9 copay | $0 copay | $9 copay |
| Tier 2: Generic | $9 copay | $18 copay | $7.5 copay | $18 copay |
| Tier 3: Preferred Brand | $102 copay | $135 copay | $85 copay | $135 copay |
| Tier 4: Non-Preferred Drug | 34% coinsurance | 45% coinsurance | 34% coinsurance | 45% coinsurance |
| Tier 5: Specialty Tier |