|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||Specialty drugs are available in only a 30-day supply|
|Preferred (Tier 5) tobacco cessation drugs||$0 copay||$0 copay|
Pharmacy out-of-pocket maximum
The annual out-of-pocket maximum is $6,550. 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.
- No coverage gap.
- Pharmacy benefits generally cover up to a 30- or 90-day supply. Specific therapeutic categories, medications and/or dosage forms may have more restrictive quantity and/or duration of therapy limitations.
- Some medications require prior authorization.