CenterWell Pharmacy ™
N/A 30-day supply 90-day supply* 30-day supply 90-day supply* 
Tier 1: Preferred Generic $1 $3 $0 $0 
Tier 2: Generic $2 $6 $1 $0 
Tier 3: Preferred Brand 23% 23% 19% 15% 
Tier 4: Non-Preferred 
Drug 45% 45% 41% 30% 
Tier 5: Specialty Tier 25% N/A 25% N/A S5884138000SB23 Summary of Benefits 7S5884138000 
Retail Cost-Sharing 
Pharmacy options Standard All other network retail 
pharmacies.  Preferred 
To find the preferred cost-share 
retail pharmacies near you, go to