$1.45 copay; or  
$4.15 copay ;or 
15% of the cost 
For all other drugs, 
either: $0 copay; or  
$4 .30 copay; or  
$10.35 copay ;or 
15%  of the cost  $0 copay; or  
$4 .30 copay; or  
$10.35 copay ;or 
15% of the cost  
Other pharmacies are available in our network. 
*Some drugs are limited to a30-day supply  
ADDITIONAL DRUG COVERAGE 
Erectile dysfunction (ED) drugs Covered at Tier 1cost-share amount. 
Anti-Obesity drugs Covered at Tier 2cost-share amount.