$4 copay; or  
$9.85 copay ;or 
15%  of the cost  $0 copay; or  
$4 copay; or  
$9.85 copay ;or 
15% of the cost  
ADDITIONAL DRUG COVERAGE 
Erectile dysfunction (ED) 
drugs Covered at Tier 1cost-share amount. 
Prescription Vitamins Covered at Tier 1cost-share amount. 
This plan participates in the Insulin Savings Program which provides affordable, predictable copayments 
on Select Insulins through the first three drug payment stages (Deductible (if applicable), Initial Coverage