Prescriptions & Pharmacies

Your share of the cost when you get a one-month (30-day) supply (or less) of a covered Part D prescription drug from:

Your share of the cost when you get a long-term (90-day) supply of a covered Part D prescription drug from: 

Network Pharmacy

The plan’s mail order service

Network long-term care pharmacy

Out-of-network Pharmacy

Network Pharmacy

The plan’s mail order service

Cost Share Tier 1  - preferred generic drugs and select preferred brand name drugs

Preferred Network

 $0 

N/A

 N/A

N/A

$0

N/A

Non-preferred Network 

$4

$4

$4

$4 plus the cost difference between the Network and Non-Network Pharmacy

$12

$10

Cost Share Tier 2 – non-preferred generic drugs and select preferred brand name drugs

Preferred Network 

$6

N/A

N/A

N/A

$18

N/A

Non-preferred Network

$10

$10

$10

$10 plus the cost difference between the Network and Non-Network Pharmacy

$30

$25

 Cost Share Tier 3 – preferred brand name drugs and select non-preferred generic drugs 

Preferred Network

$40

N/A

N/A

N/A

$120

N/A

Non-preferred Network

$45

$45

$45

$45 plus the cost difference between the Network and Non-Network Pharmacy

$135

$112.50

 Cost Share Tier 4 – non-preferred brand name drugs and select non-preferred generic drugs 

Preferred Network

$90

N/A

N/A

N/A

$270

N/A

Non-preferred Network

$90

$90

$90

$90 plus the cost difference between the Network and Non-Network Pharmacy

$270

$225

Cost Share Tier 5 – specialty  drugs 

Preferred Network

33%

N/A

N/A

N/A

33%

N/A

Non-preferred Network

33%

33%

33%

33% plus the cost difference between the Network and Non-Network Pharmacy

33%

33%