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Formulary Prescription Drug Benefits at Network Retail Pharmacies and Mail Order
Remember, under Class II, this benefit is limited to preventive healthcare drugs and supplies.
Prescription Drug Benefits—What You Pay (per prescription) Retail Pharmacy up to a 34-day supply Mail Order Pharmacy up to a 60-day supply
Preventive Healthcare Services Drugs $0
Generic and Some Brand Drugs $1
Preferred Drugs $15
Non-Preferred Drugs $30
Select Specialty and Select Biosimilar Drugs* Not covered Generic Brand
$1 25%
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 of the specialty pharmacy.


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

In Network

Out of Network

United Drug
Winn Dixie
Martins/Giant/Stop & Shop
Kroger/Fred Meyer/Fry's/King Soopers
Tom Thumb

Duane Reade
USA Drugs
Certain independent local pharmacies


Remember: Don't go out of network, you will pay 100% of the cost!

Find your nearest network pharmacy here

Other Information

Formulary Lists

You can get diabetic supplies from any retail pharmacy that’s in the network or by mail order. If you need a new glucometer, get one for FREE:

These are programs your doctor MUST use:

  • Prior Authorization. Your doctor must request approval for all Specialty and Biosimilar drugs and some Preferred and Non-Preferred Brand Name drugs before the prescription is picked up. If you need to take a drug that requires prior authorization, your doctor must call (844) 813-3860.
  • Step Therapy. Before using some drugs that are very expensive, you and your doctor must try less expensive drugs that are proven to work just as well—sometimes they even have the same ingredients.
  • Quantity Limit Program. This is sometimes called “dispensing limits.”  There are certain prescription drugs that many providers prescribe at higher dosages than the FDA considers to be safe. Coverage for these prescription drugs will be limited to a 30-day supply.

These programs save you and your health fund money, keep you safe, and prevent abuse and fraud.

We know it is sometimes medically necessary to take a drug even if it is the more expensive option. In these situations, your doctor must get approval by calling (844) 813-3860.

Medications may be added to the Step Therapy and prior authorization lists throughout the year. If your prescription is ever affected by this, we will notify you before the change.

Specialty Drugs
These include drugs used to treat health conditions such as growth hormone deficiency, hepatitis C, immune deficiency, hemophilia, multiple sclerosis and rheumatoid arthritis.

  • We work with WellDyne Specialty Pharmacy to get the best service and the best prices. If you need a specialty drug, you MUST get them through this specialty pharmacy. Your doctor MUST first get approval by calling: (800) 641-8475.
  • We will help you with this transition process. If you are currently taking a Specialty drug, have your doctor call us at (844) 857-5772 to learn how to transition to WellDyne Specialty Pharmacy.
  • Because of an exciting new program we are using, you may pay less some months for your Specialty drugs than the listed maximum copay—we will provide details when we contact you.

Mail order pharmacy program:

  • Your plan will send medicine straight to your mailbox and it costs less!
  • To enroll, call our Mail Order Pharmacy partner, WelldyneRx, at (844) 813-3860.