| Prescription Cost-Sharing (up to a 30-day supply) |
|
UHS Tang Pharmacy |
Participating Retail Pharmacy (Outside UHS) |
Non-Participating Retail Pharmacy |
| Tier 1 (Generics) |
$10 co-pay |
$20 co-pay |
$20 co-pay; then 50% up to $250 plus all charges in excess of the participating pharmacy’s negotiated charge |
| Tier 2 (Preferred Brand Name) |
$25 co-pay |
$40 co-pay |
$40 co-pay; then 50% up to $250 plus all charges in excess of the participating pharmacy’s negotiated charge |
| Tier 3 (Non-Preferred Brand Name) |
$40 co-pay |
$60 co-pay |
$60 co-pay; then 50% up to $250 plus all charges in excess of the participating pharmacy’s negotiated charge |
| Specialty Medications |
$75 co-pay |
20%, up to $250 |
Not covered |
