Tier 2: Generic $0 $0 $0 $0 
Tier 3: Preferred Brand $45 $135 $45 $125 
Tier 4: Non-Preferred 
Drug $95 $285 $95 $275 
Tier 5: Specialty Tier 33% N/A 33% N/A 2022 - 11 - Summary of Benefits H1036265001 
Standard cost-sharing 
Pharmacy options Retail 
All other network retail pharmacies. Mail order 
Walmart Mail ,PillPack  
N/A 30-day supply 90-day supply 30-day supply 90-day supply 
Tier 1: Preferred Generic $10 $30 $10 $30 
Tier 2: Generic $20 $60 $20 $60 
Tier 3: Preferred Brand $47 $141 $47 $141