Page 17 - SOLO Member Guidebook
P. 17

50% ($200 Deductible)  $500 Coins Max per Script


              Tier 4









                 50% ($200 Deductible)  $150 Coins Max per Script


              Tier 3










                $30 ($200 Deductible)



              Tier 2











              Tier 1  $5
























              PRESCRIPTION DRUG OPTION Option I – 30-Day supply through participating retail pharmacies      (Copay is 2X through mail-order)  POS DED PLANS – 2 OF 2












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