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Participating Retail Pharmacy Non-Formulary Drugs
$200 copay for 30-day retail supply
Participating Retail Tier 5: Other Brand Name Specialty Drugs
$200 copay for 30-day retail supply Retail benefit limited to […]
Participating Retail Pharmacy Tier 4: Preferred Specialty Drugs
$100 copay for 30-day supply Retail benefit limited to 30-day […]
Participating Retail Pharmacy Specialty Drugs
$75 copay for 30 day retail supply
Participating Retail Pharmacy Preferred Brand/Non-Preferred Brand Formulary Drugs
$50 copay for 30-day retail supply
Participating Retail Pharmacy Other Generics
$15 copay for 30-day retail supply
Participating Retail Pharmacy Generics for Maintenance Medications
$3 copay for 30-day retail supply
Participating Retail Pharmacy Specialty Drugs
Subject to Kaiser’s determination. Contact Kaiser for details. 20% coinsurance […]
Participating Retail Pharmacy Preferred and Non-Preferred Brand Drugs
$30 copay for up to 30-day retail supply
Participating Retail Pharmacy Generic Drug
$10 copay for up to 30-day retail supply
Participating Retail Pharmacy Tier 3: Other Brand Name Drugs
$30 copay for 30-day retail supply
Participating Retail Pharmacy Tier 2: Preferred Brand Name Drug
$30 copay for 30-day retail supply
Participating Retail Pharmacy Tier 1: Generic Drug
$7 copay for 30-day retail supply
Participating Retail Pharmacy Family Annual Out-of-Pocket Maximum
$4,200 (combined with Mail Service and Non-Participating Retail Pharmacy)
Participating Retail Pharmacy Individual Annual Out-of-Pocket Maximum
$3,600 (combined with Mail Service and Non-Participating Retail Pharmacy)