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Tier
Name
Co-pay
Tier 1
Generics
$5.50 co-pay
Tier 2
Brands
25% co-pay
Tier 3
Specialty
25% co-pay
Tier 4
Non-Preferred Brands
35% co-pay
Monthly Premium: $14.70
Tier
Name
Co-pay
Tier 1
Generics
$5 co-pay
Tier 2
Preferred Brands
35% co-pay
Tier 3
Specialty
25% co-pay
Tier 4
Non-Preferred Brands
45% co-pay
Monthly Premium: $21.70
Tier
Name
Co-pay
Tier 1
Generics
$5 co-pay
Tier 2
Brands
35% co-pay
Tier 3
Specialty
25% co-pay
Tier 4
Non-Preferred Brands
45% co-pay
Monthly Premium: $42.50
Receiving Extra Help(LIS)
Receiving Extra Help(LIS)
Receiving Extra Help(LIS)