Benefit Explanation: The cost share shown is the most common amount paid by a member for drugs in this category.? Some drugs may fall under a higher or lower cost sharing amount than is listed here. For the cost share of a specific drug, see the list of covered drugs and the Summary of Benefits. Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. Insulin: $75 max out of pocket for 30 day supply prior to deductible.
Non Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Limit Quantity: 30
Limit Unit : Days per Month
Benefit Explanation: The cost share shown is the most common amount paid by a member for drugs in this category.? Some drugs may fall under a higher or lower cost sharing amount than is listed here. For the cost share of a specific drug, see the list of covered drugs and the Summary of Benefits. Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. Insulin: $75 max out of pocket for 30 day supply prior to deductible.
Generic Drugs
CoPay: $20.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 30
Limit Unit : Days per Month
Benefit Explanation: The cost share shown is the most common amount paid by a member for drugs in this category.? Some drugs may fall under a higher or lower cost sharing amount than is listed here. For the cost share of a specific drug, see the list of covered drugs and the Summary of Benefits. Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. Insulin: $75 max out of pocket for 30 day supply prior to deductible.
Specialty Drugs
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Limit Quantity: 30
Limit Unit : Days per Month
Benefit Explanation: Tier 5 Specialty Drugs - 50% up to $200 per 30-day script cap. The cost share shown is the most common amount paid by a member for drugs in this category. Some drugs may fall under a higher or lower cost sharing amount than is listed here. For the cost share of a specific drug, see the list of covered drugs and the Summary of Benefits. Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. Insulin: $75 max out of pocket for 30 day supply prior to deductible.
1-817-813-4562, TTY 711
