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 Network Pharmacy
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 $25 and a maximum of $50, then the Plan pays 100%
In-network coverage only
Tier 2
Brand Drugs designated as preferred on the Prescription Drug List
30%, subject to a minimum of $50 and a maximum of $100, then the Plan pays 100%
In-network coverage only
Tier 3
Brand Drugs designated as non- preferred on the Prescription Drug List
40%, subject to a minimum of $100 and a maximum of $200, then the Plan pays 100%
In-network coverage only
Tier 4
Specialty Prescription Drug Products
50%, subject to a minimum of $75 and a maximum of $150, then the Plan pays 100%
In-network coverage only
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