Western PA/Susquehanna Member Guide

19 Understanding your drug costs Here are the copays for your Part D prescription drug coverage. Remember, Tier 1 preferred generic drugs have a $0 copay when filled at a preferred pharmacy or through mail order. You can see a list of all preferred generic medications, including diabetic generic medications, at upmchp.us/prescription-coverage. These copays apply only during the Initial Coverage Stage. 30-day supply 90-day supply Tier Preferred pharmacy Standard pharmacy Preferred pharmacy Standard pharmacy Mail order Tier 1 Preferred Generic $0 copay $15 copay $0 copay $30 copay $0 copay Tier 2 Generic $10 copay $20 copay $20 copay $40 copay $20 copay Tier 3 Preferred Brand $47 copay $47 copay $117.50 copay $141 copay $117.50 copay Tier 4 Non-Preferred $100 copay $100 copay $300 copay $300 copay $300 copay Tier 5 Specialty 33% coinsurance 33% coinsurance Not offered Not offered 33% coinsurance limited to a 30-day supply If you receive Extra Help (Low Income Subsidy) from Medicare for prescription drug costs, you may have a lower copay or coinsurance than what is listed above. You may not receive cost savings from using a preferred pharmacy.