Prescription medications | 30-day supply | 90-day supply |
---|---|---|
Generic (Tier 1) drugs | Up to $10 copay | Up to $25 copay |
Preferred (Tier 2) drugs | Up to $45 copay | Up to $90 copay |
Non-preferred (Tier 3) drugs | Up to $75 copay | Up to $150 copay |
Specialty (Tier 4) drugs | Generic – $10 copay Preferred – $100 copay Non-Preferred – $200 copay |
30-day copay applies to each 30-day supply |
Preferred tobacco cessation | $0 copay | $0 copay |
Insulin | Up to $30 copay. Copay is applied before the deductible. | Up to $90 copay. Copay is applied before the deductible. |
Vaccinations | $0 copay | $0 copay |
Pharmacy out-of-pocket maximum The annual out-of-pocket maximum is $2,000. Only your copays for covered prescription drugs purchased at network pharmacies count toward the out-of-pocket maximum. Once you reach the pharmacy out-of-pocket maximum, you pay $0 for covered prescription drugs purchased at network pharmacies for the remainder of the calendar year. |
- Pharmacy benefits generally cover up to a 30- or 90-day supply. Specific therapeutic categories, drugs and/or dosage forms may have more restrictive quantity and/or duration of therapy limitations.
- Some drugs require prior authorization.