Benefit Documents

Use the tabs below to find your plan's benefit documents.
Retail Prescriptions
Plan Name

Generics 

(Tier 1)

Preferred Brand Drugs 

(Tier 2)

Non-Preferred Brand Drugs 

(Tier 3)

Specialty Drugs 

(Tier 3)

Platinum $10 $25 $50 $50
Gold $20 $40 $60 $60
Low Gold $25 $50 after deductible $125 after deductible  $125 after deductible
Silver A $30 $60  $100 after deductible  $100 after deductible 
Silver A II $30 $60  $100 after deductible  $100 after deductible 
Silver B $30 after deductible 35% after deductible  35% after deductible  35% after deductible 
Bronze $30 $60 after deductible  $125 after deductible  $125 after deductible 
Mail-Order Prescriptions
Plan Name

Generics 

(Tier 1)

Preferred Brand Drugs 

(Tier 2)

Non-Preferred Brand Drugs 

(Tier 3)

Specialty Drugs 

(Tier 3)

Platinum $20 $50 $150 $150
Gold $40 $80 $180 $180
Low Gold $50 $100 $375 $375
Silver A $60 $120 $300 after deductible  $300 after deductible 
Silver A II $60 $120  $300 after deductible  $300 after deductible 
Silver B $60 after deductible 35% after deductible  35% after deductible  35% after deductible 
Bronze $60 $120 after deductible  $375 after deductible  $375 after deductible 
Retail Prescriptions
Plan Name

Generics 

(Tier 1)

Preferred Brand Drugs 

(Tier 2)

Non-Preferred Brand Drugs 

(Tier 3)

Specialty Drugs 

(Tier 3)

Platinum $10 $25 $50 $50
Gold $20 $40 $60 $60
Low Gold $25 $50 after deductible $125 after deductible  $125 after deductible
Silver A $30 $60  $100 after deductible  $100 after deductible 
Silver A II $30 $60  $100 after deductible  $100 after deductible 
Silver B $30 after deductible 35% after deductible  35% after deductible  35% after deductible 
Bronze $30 $60 after deductible  $125 after deductible  $125 after deductible 
Mail-Order Prescriptions
Plan Name

Generics 

(Tier 1)

Preferred Brand Drugs 

(Tier 2)

Non-Preferred Brand Drugs 

(Tier 3)

Specialty Drugs 

(Tier 3)

Platinum $20 $50 $150 $150
Gold $40 $80 $180 $180
Low Gold $50 $100 $375 $375
Silver A $60 $120 $300 after deductible  $300 after deductible 
Silver A II $60 $120  $300 after deductible  $300 after deductible 
Silver B $60 after deductible 35% after deductible  35% after deductible  35% after deductible 
Bronze $60 $120 after deductible  $375 after deductible  $375 after deductible 

Drug Type

Tier

Retail Copay (1 Month Supply)

Mail Order Copay (3 Month Supply)

Generic Drugs

For high blood pressure, high cholesterol & diabetes 

Tier 1 $1.00 $1.00

Generic Drugs

All covered over-the-counter and prescription drugs

Tier 1


$3.65 $3.65
Brand Drugs

Tier 2


$3.65 $3.65
Retail Prescriptions

Plan Name

Generics (Tier 1)

Preferred Brand Drugs (Tier 2)

Non-Preferred Brand Drugs (Tier 3)

Specialty Drugs

ConnectorCare Type I $1 $3.65 $3.65 $3.65
ConnectorCare Type II $10 $20 $40 $40
ConnectoreCare Type III $12.50 $25 $50 $50
ConnectorCare Zero & Limited Cost Share Select  $0 $0 $0  $0
ConnectorCare Zero & Limited Cost Share Silver  $0 $0  $0  $0 
Mail-Order Prescriptions
Plan Name
Generics (Tier 1) Preferred Brand Drugs (Tier 2) Non-Preferred Brand Drugs (Tier 3) Specialty Drugs 
ConnectorCare Type I $2 $7.30 $7.30 $7.30
ConnectorCare Type II $20 $40  $80 $80
ConnectoreCare Type III $25 $50 $100 $100
ConnectorCare Zero & Limited Cost Share Select $0  $0 $0  $0 
ConnectorCare Zero & Limited Cost Share Silver $0  $0  $0  $0 
Please see the ConnectorCare Evidence of Coverage and Schedule of Benefits for additional information, including covered and non-covered benefits; any restrictions to services, benefits or the provider network; and a summary of pharmaceutical management procedures. Click the ‘Find a Doctor, Hospital, or Pharmacy’ link at the top right of the page to find out about our providers. Please see Your Privacy for our privacy policies. Please see a summary of utilization management procedures.
Retail Prescriptions
Plan Name

Generics 

(Tier 1)

Preferred Brand Drugs 

(Tier 2)

Non-Preferred Brand Drugs 

(Tier 3)

Specialty Drugs 

(Tier 3)

Platinum $10 $25 $50 $50
Gold $20 $40 $60 $60
Low Gold $25 $50 after deductible $125 after deductible  $125 after deductible
Silver A $30 $60  $100 after deductible  $100 after deductible 
Silver A II $30 $60  $100 after deductible  $100 after deductible 
Silver B $30 after deductible 35% after deductible  35% after deductible  35% after deductible 
Bronze $30 $60 after deductible  $125 after deductible  $125 after deductible 
Mail-Order Prescriptions
Plan Name

Generics 

(Tier 1)

Preferred Brand Drugs 

(Tier 2)

Non-Preferred Brand Drugs 

(Tier 3)

Specialty Drugs 

(Tier 3)

Platinum $20 $50 $150 $150
Gold $40 $80 $180 $180
Low Gold $50 $100 $375 $375
Silver A $60 $120 $300 after deductible  $300 after deductible 
Silver A II $60 $120  $300 after deductible  $300 after deductible 
Silver B $60 after deductible 35% after deductible  35% after deductible  35% after deductible 
Bronze $60 $120 after deductible  $375 after deductible  $375 after deductible 
Please see the Qualified Health Plan Evidence of Coverage and Schedule of Benefits for specific information on each plan, including covered and non-covered benefits; any restrictions to services, benefits or the provider network; and a summary of pharmaceutical management procedures. Click the ‘Find a Doctor, Hospital, or Pharmacy’ link at the top right of the page to find out about our providers. Please see Your Privacy for our privacy policies. Please see a summary of utilization management procedures.
To request a printed copy of the Member Handbook, please contact Member Services.

Some procedures or services require prior authorization, or prior approval, from us. You or your doctor may confirm if the service requires a prior authorization by checking our Medical Procedure Code Lookup Tool or our Supplies and Services Code Lookup Tool.

We're always working to improve the quality of our services for members. If you're interested in learning more, you can read our Quality Improvement Work Plan Evaluation.

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