Tier 4: Non-Preferred 
Drug $100 $300 
Tier 5: Specialty Tier 33% N/A 
Your plan participates in the Insulin Savings Program. You will pay no more than $35 for aone-month (up 
to a30-day) supply for Select Insulins, no matter what cost-sharing tier it’s on .To identify which Select 
Insulins are included within the Insulin Savings Program, look for the  ISP indicator in your Prescription 
Drug Guide. You are not eligible for this program if you receive "Extra Help".