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Tier Copay Amount
Tier 1
Generic drugs
$0 copay or $1.35 to $3.95 copay for a 30-day supply,
depending on your income and
level of Medical Assistance (Medicaid) eligibility
Tier 1
Brand drugs
$0 copay or $4.00 to $9.85 copay for a 30-day supply,
depending on your income and
level of Medical Assistance (Medicaid) eligibility
Over-the-Counter $0 copay