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In-network pharmacy benefits

These costs are for a one-month supply when you use a retail or mail order pharmacy that accepts this plan. That's called getting your prescription in-network.

Your deductible

Be sure to compare your before and after deductible costs. It makes a big difference in what you have to pay.

  • $250 for an individual
  • $500 for a family (two or more members)
Drug tier When you pay What you pay
Tier 1a - Preferred Generic Before deductible All costs
After deductible $4
Tier 1b - Nonpreferred Generic Before deductible All costs
After deductible $20
Tier 2 - Preferred brand Before deductible All costs
After deductible No more than $100
Tier 3 - Nonpreferred brand Before deductible All costs
After deductible No more than $100
Tier 4 - Preferred specialty Before deductible All costs
After deductible No more than $200
Tier 5 - Nonpreferred specialty Before deductible All costs
After deductible No more than $300

Out-of-network benefits

In most cases, this plan doesn't cover prescriptions from an out-of-network pharmacy.