Preferred Brand Drugs | - CoPay: $60.00 Copay after deductible
- CoInsurance: Not Applicable
- Covered: Covered
- Benefit Explanation: Please see plans Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
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Non Preferred Brand Drugs | - CoPay: $90.00 Copay after deductible
- CoInsurance: Not Applicable
- Covered: Covered
- Benefit Explanation: Please see plans Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
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Generic Drugs | - CoPay: $18.00
- CoInsurance: Not Applicable
- Covered: Covered
- Benefit Explanation: Please see plans Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
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Specialty Drugs | - CoPay: Not Applicable
- CoInsurance: 20.00% Coinsurance after deductible
- Covered: Covered
- Benefit Explanation: Please see plans Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
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