Benefit Documents
Use the tabs below to select your plan type and view your plan's benefit documents.
| 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 |
| 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 |
| 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 |
| 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 |
|
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 |
| 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.
| 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 |
| 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.