Prescription Drug Coverage
Expanded Preventive Generic
Expanded Preventive Preferred Brand
Generic
Preferred brand
Non-preferred brand
Specialty
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Retail 30 Day Supply
$10 Copay
$25 Copay
$10 Copay after Deductible
$25 Copay after Deductible
50%* After Deductible
$200 Copay after Deductible
|
Mail Order 90 Day Supply
$20 Copay
$50 Copay
$20 Copay after Deductible
$50 Copay after Deductible
50%* After Deductible
Not Available
|