Tier 1 (Preferred generic drugs): $10 copay per 30-day supply
Tier 2 (Preferred brand drugs): $15 copay per 30-day supply
Tier 3 (Non preferred generic and brand drugs): $100 copay per 30-day supply
Tier 4 (Specialty drugs): 25% coinsurance per 30-day supply
Home Delivery (Preferred Drugs)
Tier 1 (Preferred generic drugs): $5 copay per 30-day supply
Tier 2 (Preferred brand drugs): $7.50 copay per 30-day supply
Tier 3 (Non preferred generic and brand drugs): $50 copay per 30-day supply
Tier 4 (Specialty drugs): 25% coinsurance per 30-day supply
Benefit Limits
The member pays copays and coinsurance as listed above for drug costs between $0 and $2,960. After reaching $2,960, the member is covered for generic and brand drugs, until the member qualifies for catastrophic coverage.
Catastrophic
Catastrophic coverage is when a member reaches $3,700 of true out-of-pocket (TrOOP) costs for the calendar year. The member will then pay either a $3.30 copay for generic ($8.25 copay for brand drugs), or a 5% coinsurance, whichever is the greater amount.