Prescription Rx Plan
| Prescription Drug | Retail (30-day supply) | Retail (90-day supply) | Mail Order (90-day supply) | |||
|---|---|---|---|---|---|---|
| Preventive Drugs | $0 | |||||
| Tier 1 | $10 copay | $25 copay | $25 copay | |||
| Tier 2 | $35 copay | $88 copay | $88 copay | |||
| Tier 3 | $70 copay | $175 copay | $175 copay | |||
| Specialty Tier 1 | $10 copay | Not Covered | Not Covered | |||
| Speciality Tier 2 | $100 copay | Not Covered | Not Covered | |||
| Specialty Tier 3 | $200 copay | Not Covered | Not Covered | |||