What You Will Pay
Common Medical Event
Limitations, Exceptions, & Other Important Information
Services You May Need
In-Network Provider (You will pay the least)
Out-of-Network Provider (You will pay the most)
20% coinsurance but not less than $15 or more than $30/prescription (retail 30 days), 20% coinsurance but not less than $30 or more than $60/prescription(home delivery 90 days) Deductible does not apply 30% coinsurance but not less than $30 or more than $60/prescription (retail 30 days), 30% coinsurance but not less than $60 or more than $120/prescription(home delivery 90 days) Deductible does not apply 40% coinsurance but not less than $60 or more than $120/prescription (retail 30 days), 40% coinsurance but not less than $120 or more than $240/prescription(home delivery 90 days) Deductible does not apply
Generic drugs (Tier 1)
Not covered
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.express-scripts.com/rx
If you elect to fill a brand name drug when there is a generic available, you will pay the brand drug cost plus the difference between the brand and generic drug cost.
Preferred brand drugs (Tier 2)
Not covered
Non-preferred brand drugs (Tier 3)
Not covered
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