Non-Preferred Brand $25 copay 20% coinsurance; Plan pays 80% Plan pays 100% Contraceptives Plan pays 100% N/A Plan pays 100% Day Supply Limit 30 days 30 days 90 days Retired after 10/2/2011 Acute Medications Mail Order1 Participating Non-Participating Maintenance Health Enhancement Retail Pharmacy Retail Pharmacy Medications Program Participants Generic $5 copay 20% coinsurance; $5 copay $0 copay Plan pays 80% Preferred Brand $20 copay 20% coinsurance; $10 copay $5 Plan pays 80% Non-Preferred Brand $35 20% coinsurance; $25 copay $12.50 copay Plan pays 80% Contraceptives2 Plan pays 100% N/A Plan pays 100% Plan pays 100% Day Supply Limit 30 days 30 days 90 days 90 days Retired after 10/2/2017 Acute Medications Mail Order Health Enhancement Participating Non-Participating Maintenance Program Retail Pharmacy Retail Pharmacy Medications1 Participants3 Preferred Generic $5 copay 20% coinsurance; Plan $5 $0 copay pays 80% Non-Preferred $10 copay 20% coinsurance; Plan $10 copay $0 copay Generic pays 80% Preferred Brand $25 copay 20% coinsurance; Plan $25 copay $5 copay pays 80% Non-Preferred $40 copay 20% coinsurance; Plan $40 copay $12.50 copay pays 80% Contraceptives2 Plan pays 100% N/A Plan pays Plan pays 100% 100% Day Supply Limit 30 days 30 days 90 days 90 days
Non-Preferred Brand $25 copay 20% coinsurance; Plan pays 80% Plan pays 100% Contraceptives Plan pays 100% N/A Plan pays 100% Day Supply Limit 30 days 30 days 90 days Retired after 10/2/2011 Acute Medications Mail Order1 Participating Retail Pharmacy Non-Participating Retail Pharmacy Maintenance Medications Health Enhancement Program Participants Generic $5 copay 20% coinsurance; Plan pays 80% $5 copay $0 copay Preferred Brand $20 copay 20% coinsurance; Plan pays 80% $10 copay $5 Non-Preferred Brand $35 20% coinsurance; Plan pays 80% $25 copay $12.50 copay Contraceptives2 Plan pays 100% N/A Plan pays 100% Plan pays 100% Day Supply Limit 30 days 30 days 90 days 90 days Retired after 10/2/2017 Acute Medications Mail Order Participating Retail Pharmacy Non-Participating Retail Pharmacy Maintenance Medications1 Health Enhancement Program Participants3 Preferred Generic $5 copay 20% coinsurance; Plan pays 80% $5 $0 copay Non-Preferred Generic $10 copay 20% coinsurance; Plan pays 80% $10 copay $0 copay Preferred Brand $25 copay 20% coinsurance; Plan pays 80% $25 copay $5 copay Non-Preferred $40 copay 20% coinsurance; Plan pays 80% $40 copay $12.50 copay Contraceptives2 Plan pays 100% N/A Plan pays 100% Plan pays 100% Day Supply Limit 30 days 30 days 90 days 90 days
State%20of%20CT_2018_Plan%20Document_Pharmacy%20Plan_Final.docx