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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
$345 $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 drugs
$345 50% coinsurance 50% coinsurance Available for 50% coinsurance
Tier 5
Specialty drugs
$345 27% coinsurance 27% coinsurance Available for 27% coinsurance




Important Message About What You Pay for Vaccines - Our plan covers most Part D vaccines at no cost to you, even if you haven’t paid your deductible. Call Customer Service for more information.


Important Message About What You Pay for Insulin - You won’t pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it’s on, even if you haven’t paid your deductible.