Prescription Drug Copays Partnership PPO (promise and no promise) Standard PPO HealthSavings CDHP In-Network Out-of-Network Out-of- Network 30-Day Supply (only from pharmacies in the 30-day network) $7 copay generic $40 copay preferred brand $90 copay non- preferred brand Copay, plus any amount exceeding MAC $14 copay for generic $50 copay for preferred brand $100 copay for non-preferred brand Copay, plus any amount exceeding MAC After deductible is met - 20% coinsurance After deductible is met - 40% coinsurance plus amount exceeding MAC 90-Day Supply (90-day network pharmacy or mail order) $14 copay generic $80 copay preferred brand $180 copay non- preferred brand N/A – no network $28 copay for generic $100 copay for preferred brand $200 copay for non-preferred brand (certain maintenance medications from 90-day pharmacy or mail order) $160 copay non- preferred brand $50 copay preferred brand 10% coinsurance without first having to meet deductible Specialty Tier (coinsurance) 10% (min $50; max $150) 20% after deductible While the coverage for prescription drugs is the same for plans, the copays will be less expensive in the Partnership PPO. With the CDHP option, you must pay the full negotiated cost for drugs up to the deductible. Then, your coinsurance kicks in. You can save money by using the 90-day network to receive your medications through mail order or at a participating “mail at retail” pharmacy. Please note: Specialty medications have a 30-day supply limit and must be filled at a CVS/Caremark specialty network pharmacy. You can see from the chart that copays and co-insurance are lower for certain maintenance medications, when you use the mail order benefit or a 90-day network retail pharmacy. These specific maintenance medications include statins, antihypertensives and meds for asthma, COPD, depression, coronary artery disease, congestive heart failure and oral diabetic medications, insulins and supplies. Please note that diabetic supplies include needles, test trips and lancets only. www.partnersforhealthtn.gov 800-253-9981