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Tier
Name
Co-pay
Tier 1
Preferred Generics
$3.50
Tier 2
Preferred Brand
25% co-pay
Tier 3
Specialty
25% co-pay
Tier 4
Non-Preferred
45% co-pay
Monthly Premium: $35.40
Tier
Name
Co-pay
Tier 1
Value Generics
$2.50 co-pay (Only Available at CVS/Pharmacy) $5.00 co-pay at all other network pharmacies
Tier 2
Generics
$5.00 co-pay
Tier 3
Preferred Brand
33% co-pay
Tier 4
Specialty
33% co-pay
Tier 5
Non-Preferred
45% co-pay
Monthly Premium: $49.30
Star Materials
Freedom Materials
Comprehensive Formulary*
Comprehensive Formulary*
Summary of Benefits*
Summary of Benefits*
Evidence of Coverage*
Evidence of Coverage*
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Receiving Extra Help(LIS)
Receiving Extra Help(LIS)
