Prescription Plan

Gold Plan 

In-Network

Gold Plan

Out-of-Network

Retail - 30-day supply



  • Generic
  • Preferred Brand 
  • Non-preferred Brand 
  • Specialty

x

x

Retail - 90-day supply
  • Generic
  • Preferred Brand 
  • Non-preferred Brand 
  • Specialty

x

x

Silver Plan

In-Network

Silver Plan

Out-of-Network

Retail - 30-day supply



  • Generic
  • Preferred Brand 
  • Non-preferred Brand 
  • Specialty

x

x

Mail Order – 90-day supply

  • Generic
  • Preferred Brand 
  • Non-preferred Brand 
  • Specialty

x

x

Bronze Plan

In-Network

Bronze Plan

In-Network

Retail - 30-day supply

  • Generic
  • Preferred Brand 
  • Non-preferred Brand 
  • Specialty

x

x

Mail Order – 90-day supply
  • Generic
  • Preferred Brand
  • Non-preferred Brand 
  • Specialty

x

x