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Benefit

In-Network

Out-of-Network Plans
     

96 1A
96 1B

97 1A
97 1B

97 2A
97 2B
  Prescription drugs at retail pharmacy (up to a 34-day supply)

96 1A, 97 1A
No cost

96 1B, 97 1B,
97 2B
$3 or $5 copayment

97 2A
$1 copayment

Reimbursed at average wholesale cost minus applicable in-network copayment
  Mail-order prescription drug program (mandatory for all maintenance prescription medications for up to a 90-day supply)

No cost

Not applicable
 

 
 

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