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Tier Deductible 30-Day Supply -
Preferred Cost Share
30-Day Supply -
Standard Cost Share
90-Day Supply -
Preferred Mail Order
Tier 1
Preferred generic drugs
Deductible does not apply $2 copay $7 copay Two preferred copays
Tier 2
Generic drugs
Deductible does not apply $10 copay $16 copay Two preferred copays
Tier 3
Preferred brand drugs
$245 $47 copay $47 copay Two preferred copays
Select insulins Deductible does not apply to select insulins $30 $35 Two preferred copays
Tier 4
Non-preferred drugs
$245 50% coinsurance 50% coinsurance 50% coinsurance
Tier 5
Specialty drugs
$245 29% coinsurance 29% coinsurance 29% coinsurance

Important Message About What You Pay for Vaccines - Our plan covers most Part D vaccines at no cost to you, even if you haven’t paid your deductible. Call Customer Service for more information.

Important Message About What You Pay for Insulin - You won’t pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it’s on, even if you haven’t paid your deductible.