|
Prescription Drug Coverage
Generic
Preferred Brand
Non-Preferred Brand
Specialty
|
Retail 30 Day Supply
$10 Copay after Deductible
$45 Copay after Deductible
$70 Copay after Deductible
30% Coinsurance after
Deductible, up to $150 Copay
|
Mail Order 90 Day Supply
$20 Copay after Deductible
$90 Copay after Deductible
$140 Copay after Deductible
Not Covered
|