|What you pay|
|Drugs/Supplies from the AC Free Pharmacy||FREE|
|Certain preventive drugs/supplies||$0|
|Generic drugs on the formulary||$5 copay|
|Brand name drugs on the formulary||$15 copay|
|Specialty brand or biosimilar drugs
(Specialty drugs not available with Bridge Coverage)
($20 max copay)
|Drugs NOT on the formulary||Not covered|
Brand name drug with generic available
If you or your healthcare provider insist on a brand name drug when a generic equivalent is available, you must pay the generic copay plus the difference in cost between the brand and generic drug.
If the generic copay is $10, the brand name drug is $80 and the generic is $50, you will pay $40. $10 copay plus $30 difference in cost.
For questions about your drug benefits, call: (844) 813-3860
Out of Network
Jogi Discount Pharmacy
Certain independent local pharmacies
Remember: Don't go out of network, you will pay 100% of the cost!