Rx

Schedule of Benefits 2026

(Benefit Coverage Plans A and B)

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	Benefit	Benefit Coverage Plan A		Benefit Coverage Plan B
		In-Network	Out-of-Network	In-Network	Out-of-Network
Prescription Drugs	Yearly deductible	None	None	None	None
	Maximum network out-of-pocket cost (doesn’t include clinical pharmacy program penalties)	$9,600 Individual; $19,200 Family	None	$9,600 Individual; $19,200 Family	None
	Prescription drugs at retail pharmacy (up to a 34-day supply)	Tier 1: $0 Generic Tier 2: $10 Preferred Tier 3: $20 Non-preferred	Reimbursed at contracted amount minus applicable in-network copayment	Tier 1: $7 Generic Tier 2: $20 Preferred Tier 3: $35 Non-preferred	Reimbursed at contracted amount minus applicable in-network copayment
	Mail-order prescription drug program (mandatory for all maintenance prescription medications for up to a 90-day supply)	Tier 1: $0 Generic Tier 2: $20 Preferred Tier 3: $40 Non-preferred	Not applicable	Tier 1: $15 Generic Tier 2: $40 Preferred Tier 3: $70 Non-preferred	Not applicable
	Routine vaccinations (influenza, pneumococcal disease, zoster/ shingles, and COVID-19) administered at the pharmacy	No cost	Not covered	No cost	Not covered
Prescription Drug Programs	Mandatory generics	Applies to all drugs filled at a retail pharmacy or by mail-order. If brandname is selected instead of generic, participant pays applicable copay and cost difference between generic and brand-name. This applies even if the physician writes “DAW.”		Applies to all drugs filled at a retail pharmacy or by mail-order. If brandname is selected instead of generic, participant pays applicable copay and cost difference between generic and brand-name. This applies even if the physician writes “DAW.”
	Preferred specialty drugs	Same copays as non-specialty drugs (retail and mail-order)		Same copays as non-specialty drugs (retail and mail-order)
	High performance step therapy (The practice of beginning drug therapy for a medical condition with the most cost-effective and safest drug therapy and progressing to other more costly therapy, only if necessary.)	Four therapeutic classes of drugs applies. Copay applies if step therapy guidelines are not followed: Retail copay – 25% or $50 max; Mail-order copay – 50% or $100 max (Automatic override will be applied for first or subsequent steps if the physician determines medical necessity; participant will pay only the copay associated with the prescribed drug, not the amount cited above for failing to follow step therapy guidelines.)		Four therapeutic classes of drugs applies. Copay applies if step therapy guidelines are not followed: Retail copay – 25% or $50 max; Mail-order copay – 50% or $100 max (Automatic override will be applied for first or subsequent steps if the physician determines medical necessity; participant will pay only the copay associated with the prescribed drug, not the amount cited above for failing to follow step therapy guidelines.)
	Preferred specialty pharmacy program	For growth hormone deficiency and rheumatoid arthritis class. Preferred specialty copay is standard specialty copay; non-preferred specialty copay is 10% of drug cost ($200 max)		For growth hormone deficiency and rheumatoid arthritis class. Preferred specialty copay is standard specialty copay; non-preferred specialty copay is 10% of drug cost ($200 max)