Benefit Explanation: Up to 30-day supply Retail and up to 90-day supply Retail & Mail Order, except narcotics and Specialty Drugs. Insulin will not exceed $30 for a 30-day supply and $90 for a 90-day supply.
Non Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: 0.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Up to 30-day supply Retail and up to 90-day supply Retail & Mail Order, except narcotics and Specialty Drugs.
Generic Drugs
CoPay: Not Applicable
CoInsurance: 0.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Up to 30-day supply Retail and up to 90-day supply Retail & Mail Order, except narcotics and Specialty Drugs.
Specialty Drugs
CoPay: Not Applicable
CoInsurance: 0.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Up to 30-day supply Retail only.