Standard |
Enhanced |
Complete |
|
|---|---|---|---|
Deductible |
$275.00 |
$0.00 |
$0.00 |
Generic co-pay |
25% |
$4.00 |
$4.00 |
Preferred brand co-pay |
25% |
$25.00 |
$25.00 |
Brand name co-pay |
25% |
$54.00 |
$54.00 |
Speciality drug co-pay |
25% |
25% |
25% |
Mail order3 month supply |
25% |
Preferred generic - $0 |
Preferred generic - $0 |
Preferred brand - $62.50 |
Preferred brand - $62.50 |
||
Non-preferred brand - $135.00 |
Non-preferred brand- $135.00 |
||
3 month supply at select pharmacies |
25% |
Preferred generic - $12.00 |
Preferred generic - $12.00 |
Preferred brand - $75.00 |
Preferred brand - $75.00 |
||
Non-preferred brand - $162.00 |
Non-preferred brand- $162.00 |
||
Monthly premium |
$26.50 |
$31.40 |
$94.40(includes generic Rx benefits during "gap-in-coverage" period, see below) |




