Preferred Retail Pharmacy
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Tier 1 (Generics): $5 copay up to a 30-day supply; $15 copay for a 31 to 90-day supply
Tier 2 (Preferred brand): 40% of our allowance ($350 max) for up to a 30-day supply; $1,050 maximum for 31 to 90-day supply)
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Tier 1 (Generics): $15 copay up to a 30-day supply; $40 copay for a 31 to 90-day supply
Tier 2 (Preferred brand): $60 copay for up to a 30-day supply; $180 copay for a 31 to 90-day supply
Tier 3 (Non-preferred brand): 60% of our allowance ($90 minimum) for up to a 30-day supply; $250 minimum for a 31 to 90-day supply)
Tier 4 (Preferred specialty): $85 copay
Tier 5 (Non-preferred specialty): $110 copay
Tier 4 and 5 specialty drugs are limited to a 30-day supply; only one fill allowed. All refills must be obtained from the Specialty Drug Pharmacy Program.
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Tier 1 (Generics): $7.50 copay for up to a 30-day supply; $22.50 copay for a 31 to 90-day supply
Tier 2 (Preferred brand): 30% of our allowance
Tier 3 (Non-preferred brand): 50% of our allowance
Tier 4 (Preferred specialty): 30% of our allowance
Tier 5 (Non-preferred specialty): 30% of our allowance
Tier 4 and 5 specialty drugs are limited to a 30-day supply; only one fill allowed. All refills must be obtained from the Specialty Drug Pharmacy Program.
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Mail Service Pharmacy
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Not a benefit
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Available to members with Medicare Part B primary only. Visit the Medicare page for more information.
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Tier 1 (Generics): $15 copay
Tier 2 (Preferred brand): $90 copay
Tier 3 (Non-preferred brand): $125 copay
Covers a 22 to 90-day supply. Nothing for the first 4 prescription fills or refills when you switch from certain brand name drugs to specific generic drugs.
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Specialty Pharmacy
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Tier 2 (Preferred specialty): 40% of our allowance ($350 maximum) for a 30-day supply; $1,050 maximum for 31 to 90-day supply
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Tier 4 (Preferred specialty): $85 copay
Tier 5 (Non-preferred specialty): $110 copay
90-day supply may only be obtained after third fill.
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Tier 4 (Preferred specialty): $65 copay for up to a 30-day supply; $185 copay for a 31 to 90-day supply
Tier 5 (Non-preferred specialty): $85 copay for up to a 30-day supply; $240 copay for a 31 to 90-day supply
90-day supply may only be obtained after third fill.
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