Archives
Non-Participating Tier 5: Other Brand Name Specialty Drugs
Not covered
Non-Participating Retail Tier 4: Preferred Specialty Drugs
Not covered
Non-Participating Retail Pharmacy Tier 1: Generic Drug
$7 copay plus 20% coinsurance per prescription No coverage for mail […]
Non-Participating Retail Pharmacy Tier 3: Other Brand Name Drugs
$30 copay plus 20% coinsurance per prescription No coverage for mail […]
Non-Participating Retail Pharmacy Tier 2: Preferred Brand Name Drug
$30 copay plus 20% coinsurance per prescription retail No coverage for […]
Non-Participating Retail Pharmacy Family Annual Out-of-Pocket Maximum
$4,200 (combined with Mail Service and Participating Retail Pharmacy)
Non-Participating Retail Pharmacy Family Annual Out-of-Pocket Maximum
$3,600 (combined with Mail Service and Participating Retail Pharmacy)