Individual & Family Plans Formulary (PDF) Updated 10/15/2019
| Tier | What you pay when using in-network pharmacy |
|---|---|
| Tier 1 Preferred generic drugs |
$5 copay per prescription; $10 copay for up to 90-day supply |
| Tier 2 Non-preferred generics |
$15 copay per 30-day supply; $30 copay for up to 90-day supply |
| Tier 3 Preferred Brand drugs |
$125 copay per 30-day supply; Tier 3 insulin $25 copay per 30-day supply |
| Tier 4 Non-preferred Brand drugs |
40% coinsurance after deductible |
| Tier 3 Specialty drugs |
40% coinsurance after deductible |
Prior Authorization Criteria
(PDF) Updated 10/15/2019
Step Therapy Criteria
(PDF) Updated 10/15/2019