|Formulary Prescription Drug Benefits at Network Retail Pharmacies and Mail Order||Per Prescription Copays as of 1/1/2022|
|Prescription Drug Benefits—What You Pay||Retail Pharmacy up to a 34-day supply||Mail Order Pharmacy up to a 90-day supply|
|Preventive Healthcare Services Drugs||$0|
|Generic and Some Brand Drugs||$10||$20|
|Select Specialty and Select Biosimilar Drugs*||Not covered||Generic||Brand|
|Non-Formulary Prescription Drugs and Supplies||Not covered, unless an exception is approved|
|* Current pharmacy benefit provider will actively manage and determine drugs in tier. Specialty drugs are only available through the specialty mail order pharmacy. However, effective January 1, 2022, if you take specialty medications as part of your HIV treatment plan, you may be able to receive an exception to use your network retail pharmacy instead.|
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
Martins/Giant/Stop & Shop
Kroger/Fred Meyer/Fry's/King Soopers
Certain independent local pharmacies
Remember: Don't go out of network, you will pay 100% of the cost!