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Tier
Name
Co-pay
Tier 1
Generics
$5.25 co-pay
Tier 2
Preferred Brand
25% co-pay
Tier 3
Specialty
25% co-pay
Tier 4
Non-Preferred
45% co-pay
Monthly Premium: $35.10
Tier
Name
Co-pay
Tier 1
Generics
$4.75 co-pay
Tier 2
Preferred Brand
35% co-pay
Tier 3
Specialty
33% co-pay
Tier 4
Non-Preferred
45% co-pay
Monthly Premium: $39.50
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)