NETWORK PHARMACY
NON-NETWORK PHARMACY
BENEFIT HIGHLIGHTS
Prescription Drug Products at Home Delivery Pharmacies The amount you pay for up to a consecutive 90-day supply at a non- Network Pharmacy Specialty Prescription Drug Products are limited to up to a consecutive 30-day supply per Prescription Order or Refill and are subject to the same Copayment or Coinsurance that applies to retail Pharmacies. Tier 1 Generic Drugs on the Prescription Drug List 20% after plan Deductible In-network coverage only Tier 2 Brand Drugs designated as preferred on the Prescription Drug List 20% after plan Deductible In-network coverage only Tier 3 The amount you pay for up to a consecutive 90-day supply at a Network Pharmacy
Brand Drugs designated as non- preferred on the Prescription Drug List
20% after plan Deductible
In-network coverage only
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