50% ($200 Deductible) $500 Coins Max per Script
Tier 4
50% ($200 Deductible) $150 Coins Max per Script
Tier 3
$50 ($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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