Benefit Documents

Use the tabs below to select your plan type and view 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.

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