Tier 1: Preferred Generic $0 $0 
Tier 2: Generic $0 $0 
Tier 3: Preferred Brand $42 $126 
Tier 4: Non-Preferred 
Drug $100 $300 
Tier 5: Specialty Tier 33% N/A 
Tier 6: Select Care Drugs $0 $0 
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