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Tier Deductible 30 day supply - standard cost share 30 day supply - preferred cost share 90 day supply - preferred mail order
Tier 1
Preferred generic drugs
Deductible does not apply to this tier $12 copay $2 copay Available for two preferred copays
Tier 2
Generic drugs
Deductible does not apply to this tier $20 copay $10 copay Available for two preferred copays
Tier 3
Preferred brand drugs
$395 $47 copay $47 copay Available for two preferred copays
Select insulins Deductible does not apply to select insulin $35 copay $30 copay
Tier 4
Non-preferred brand drugs
$395 50% coinsurance 45% coinsurance Available for 45% coinsurance
Tier 5
Specialty drugs
$395 25% coinsurance 25% coinsurance Available for 25% coinsurance