In-network prescriptions have a separate out-of-pocket maximum from the medical plan: $7,050 per member/$11,700 per family.
For a brand drug with a generic version, members must pay the generic copay plus the cost difference between the brand and generic.
In-network:
Cost for in-network prescriptionsService | Retail (up to 30-day supply) | Retail (31–90-day supply) | Mail order (up to 90-day supply) |
---|
Tier 1 (Generic) | $8 | $20 | $20 |
Tier 2 (Preferred Brand) | $25 | $62 | $62 |
Tier 3 (Non-Preferred Brand) | $45 | $112 | $112 |
Out-of-network:
- Retail: 50% coinsurance (plus amounts above the network’s discounted price )
- Mail order: Not covered.
Limits/exceptions: Out-of-pocket limit for in-network prescriptions is $6,800 for individual, or $11,200 for family. Copays do not apply toward your deductible.
Specialty drugs (up to 30-day supply) through Archimedes
- In-network:
- Tier 1 (generic): $20
- Tier 2 (Preferred Brand): $62
- Tier 3 (Non-Preferred Brand): $112
- Out-of-network: Not covered.
- Limits/exceptions: When using copay assistance, only the actual amount you pay counts towards your prescription out-of-pocket maximum.
Preventive medications on the No Cost Share Medication List are covered by the plan 100%.
Check drug costs for this plan