Prescription Maximum Calendar Year Out-of-pocket
| Maximum Calendar Year Out-of-pocket | Plan A In-Network | Plan A Out-of-Network | Plan B In-Network | Plan B Out-of-Network |
|---|---|---|---|---|
| Individual | $400 | N/A | $900 | N/A |
| Family | $800 | N/A | $1,800 | N/A |
Retail and Mail Order Prescription (30-day Supply)
| Tiers | Plan A In-Network | Plan A Out-of-Network | Plan B In-Network | Plan B Out-of-Network |
|---|---|---|---|---|
| Tier 1 Generic Prescription | $0 Copay | Not Covered | $0 Copay | Not Covered |
| Tier 2 Generic Prescription | $10 Copay | Not Covered | $10 Copay | Not Covered |
| Tier 3 Preferred Brand Name | $35 Copay | Not Covered | $35 Copay | Not Covered |
| Tier 4 Non-Preferred Brand Name | $50 Copay | Not Covered | $50 Copay | Not Covered |
Retail and Mail Order Prescription (90-day Supply)
| Tiers | Plan A In-Network | Plan A Out-of-Network | Plan B In-Network | Plan B Out-of-Network |
|---|---|---|---|---|
| Tier 1 Generic Prescription | $0 Copay | Not Covered | $0 Copay | Not Covered |
| Tier 2 Generic Prescription | $20 Copay | Not Covered | $20Copay | Not Covered |
| Tier 3 Preferred Brand Name | $70 Copay | Not Covered | $70 Copay | Not Covered |
| Tier 4 Non-Preferred Brand Name | $100 Copay | Not Covered | $100 Copay | Not Covered |