Tier 3: Preferred 
Brand  $35 $105 $35 $95 
Standard cost-sharing for Select Insulins 
Pharmacy 
options  Retail All other network retail 
pharmacies.  Mail Order  Walmart Mail ,PillPack 
- 30-day supply  90-day supply 30-day supply  90-day supply 
Tier 2: Generic  $20 $60 $20 $60 
Tier 3: Preferred 
Brand  $35 $105 $35 $105 
Cost sharing may change depending on the pharmacy you choose, when you enter another phase of the