Individual & Family Plans Formulary (PDF) Updated 10/15/2019
| Tier | What you pay when using in-network pharmacy |
|---|---|
| Tier 1 Preferred generic drugs |
0% coinsurance after deductible |
| Tier 2 Non-preferred generics |
0% coinsurance after deductible |
| Tier 3 Preferred Brand drug |
0% coinsurance after deductible; Tier 3 insulin $25 copay per 30-day supply |
| Tier 4 Non-preferred Brand drugs |
0% coinsurance after deductible |
| Tier 5 Specialty drugs |
0% coinsurance after deductible |
Prior Authorization Criteria
(PDF) Updated 10/15/2019
Step Therapy Criteria
(PDF) Updated 10/15/2019