Page 8 - Centennial Enrollment

Prescription Drug Plan

QHDHP $1,500 QHDHP $2,700

In-Network Out-of-Network In-Network Out-of-Network

Retail (30 days)

Deductible/$10 Deductible/$15
Tier 1 copay copay

Deductible/$30 50% (minimum Deductible/$30 50% (minimum
Tier 2 copay $60) copay $60)

Tier 3 Deductible/$60 Deductible/$50
copay copay

Mail Order (90
days)

Tier 1 Deductible/$20 Deductible/$30
copay
copay

Tier 2 Deductible/$60 Not Covered Deductible/$60 Not Covered
copay
copay
Deductible/$120 Deductible/$100
Tier 3 copay copay

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