NETWORK PHARMACY
NON-NETWORK PHARMACY
BENEFIT HIGHLIGHTS
Tier 4 Specialty Prescription Drug Products
Specialty Prescription Drug Products are limited to up to a consecutive 30 day supply per Prescription Order or Refill. The amount you pay for up to a consecutive 90-day supply at a Network Pharmacy
Specialty Prescription Drug Products are limited to up to a consecutive 30 day supply per Prescription Order or Refill.
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%, subject to a minimum of $30 and a maximum of $60, then the Plan pays 100% In-network coverage only
Tier 2 Brand Drugs designated as preferred on the Prescription Drug List Tier 3 Brand Drugs designated as non- preferred on the Prescription Drug List
30%, subject to a minimum of $60 and a maximum of $120, then the Plan pays 100%
In-network coverage only
40%, subject to a minimum of $120 and a maximum of $240, then the Plan pays 100%
In-network coverage only
Tier 4 Specialty Prescription Drug Products
Specialty Prescription Drug Products are limited to up to a consecutive 30 day supply per Prescription Order or Refill.
In-network coverage only
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