| Group Number |
Type of Drug |
Retail Copayment |
Mail Order Copayment |
| 93211300 |
Generic |
$5.00 |
$15.00 |
| 93211300 |
Brand Name |
$15.00 |
$30.00 |
| 93211300 |
Brand Name Injectables |
$30.00 |
$60.00 |
| 93211300 |
Certain expensive brand name drugs (see list) |
$30.00 |
$60.00 |
|
| Group Number |
Type of Drug |
Retail Copayment |
Mail Order Copayment |
| 93211301 |
Generic |
$5.00 |
$15.00 |
| 93211301 |
Brand Name |
$15.00 |
$30.00 |
| 93211301 |
Brand Name Injectables |
$30.00 |
$60.00 |
| 93211301 |
Certain expensive brand name drugs (see list) |
$30.00 |
$60.00 |
|
| Group Number |
Type of Drug |
Retail Copayment |
Mail Order Copayment |
| 93211310 |
Generic |
$10.00 |
$30.00 |
| 93211310 |
Brand Name |
$20.00 |
$40.00 |
| 93211310 |
Brand Name Injectables |
$40.00 |
$80.00 |
| 93211310 |
Certain expensive brand name drugs (see list) |
$40.00 |
$80.00 |
|
| Group Number |
Type of Drug |
Retail Copayment |
Mail Order Copayment |
| 93211320 |
Generic |
$10.00 |
$30.00 |
| 93211320 |
Brand Name |
$30.00 |
$60.00 |
| 93211320 |
Brand Name Injectables |
$50.00 |
$100.00 |
| 93211320 |
Certain expensive brand name drugs (see list) |
$50.00 |
$100.00 |
|
| Group Number |
Type of Drug |
Retail Copayment |
Mail Order Copayment |
| 93211400 |
Generic |
$5.00 |
$15.00 |
| 93211400 |
Brand Name |
$15.00 |
$30.00 |
| 93211400 |
Brand Name Injectables |
$30.00 |
$60.00 |
| 93211400 |
Certain expensive brand name drugs (see list) |
$30.00 |
$60.00 |
|
| Group Number |
Type of Drug |
Retail Copayment |
Mail Order Copayment |
| 93211410 |
Generic |
$10.00 |
$30.00 |
| 93211410 |
Brand Name |
$30.00 |
$60.00 |
| 93211410 |
Brand Name Injectables |
$50.00 |
$100.00 |
| 93211410 |
Certain expensive brand name drugs (see list) |
$50.00 |
$100.00 |
|
| Group Number |
Type of Drug |
Retail Copayment |
Mail Order Copayment |
| 93211500 |
Generic |
$5.00 |
$15.00 |
| 93211500 |
Brand Name |
$15.00 |
$30.00 |
| 93211500 |
Brand Name Injectables |
$30.00 |
$60.00 |
| 93211500 |
Certain expensive brand name drugs (see list) |
$30.00 |
$60.00 |
|
| Group Number |
Type of Drug |
Retail Copayment |
Mail Order Copayment |
| 93211600 |
Generic |
$5.00 |
$15.00 |
| 93211600 |
Brand Name |
$15.00 |
$30.00 |
| 93211600 |
Brand Name Injectables |
$30.00 |
$60.00 |
| 93211600 |
Certain expensive brand name drugs (see list) |
$30.00 |
$60.00 |
|
| Group Number |
Type of Drug |
Retail Copayment |
Mail Order Copayment |
| 93211610 |
Generic |
$10.00 |
$30.00 |
| 93211610 |
Brand Name |
$20.00 |
$40.00 |
| 93211610 |
Brand Name Injectables |
$40.00 |
$80.00 |
| 93211610 |
Certain expensive brand name drugs (see list) |
$40.00 |
$80.00 |
|
| Group Number |
Type of Drug |
Retail Copayment |
Mail Order Copayment |
| 93211620 |
Generic |
$10.00 |
$30.00 |
| 93211620 |
Brand Name |
$30.00 |
$60.00 |
| 93211620 |
Brand Name Injectables |
$50.00 |
$100.00 |
| 93211620 |
Certain expensive brand name drugs (see list) |
$50.00 |
$100.00 |
|
| Group Number |
Type of Drug |
Retail Copayment |
Mail Order Copayment |
| 93212020 |
Generic |
$5.00 |
$15.00 |
| 93212020 |
Brand Name |
$15.00 |
$30.00 |
| 93212020 |
Brand Name Injectables |
$30.00 |
$60.00 |
| 93212020 |
Certain expensive brand name drugs (see list) |
$30.00 |
$60.00 |
|
| Group Number |
Type of Drug |
Retail Copayment |
Mail Order Copayment |
| 93212040 |
Generic |
$5.00 |
$15.00 |
| 93212040 |
Brand Name |
$15.00 |
$30.00 |
| 93212040 |
Brand Name Injectables |
$30.00 |
$60.00 |
| 93212040 |
Certain expensive brand name drugs (see list) |
$30.00 |
$60.00 |
|
| Group Number |
Type of Drug |
Retail Copayment |
Mail Order Copayment |
| 93212050 |
Generic |
$5.00 |
$15.00 |
| 93212050 |
Brand Name |
$15.00 |
$30.00 |
| 93212050 |
Brand Name Injectables |
$30.00 |
$60.00 |
| 93212050 |
Certain expensive brand name drugs (see list) |
$30.00 |
$60.00 |
|
| Group Number |
Type of Drug |
Retail Copayment |
Mail Order Copayment |
| 93212060 |
Generic |
$5.00 |
$15.00 |
| 93212060 |
Brand Name |
$15.00 |
$30.00 |
| 93212060 |
Brand Name Injectables |
$30.00 |
$60.00 |
| 93212060 |
Certain expensive brand name drugs (see list) |
$30.00 |
$60.00 |
|
| Group Number |
Type of Drug |
Retail Copayment |
Mail Order Copayment |
| 93212070 |
Generic |
$10.00 |
$30.00 |
| 93212070 |
Brand Name |
$20.00 |
$40.00 |
| 93212070 |
Brand Name Injectables |
$40.00 |
$80.00 |
| 93212070 |
Certain expensive brand name drugs (see list) |
$40.00 |
$80.00 |
|
| Group Number |
Type of Drug |
Retail Copayment |
Mail Order Copayment |
| 93212080 |
Generic |
$10.00 |
$30.00 |
| 93212080 |
Brand Name |
$30.00 |
$60.00 |
| 93212080 |
Brand Name Injectables |
$50.00 |
$100.00 |
| 93212080 |
Certain expensive brand name drugs (see list) |
$50.00 |
$100.00 |
|
| Group Number |
Type of Drug |
Retail Copayment |
Mail Order Copayment |
| 93212090 |
Generic |
$5.00 |
$15.00 |
| 93212090 |
Brand Name |
$15.00 |
$30.00 |
| 93212090 |
Brand Name Injectables |
$30.00 |
$60.00 |
| 93212090 |
Certain expensive brand name drugs (see list) |
$30.00 |
$60.00 |
|
| Group Number |
Type of Drug |
Retail Copayment |
Mail Order Copayment |
| 93212091 |
Generic |
$5.00 |
$15.00 |
| 93212091 |
Brand Name |
$15.00 |
$30.00 |
| 93212091 |
Brand Name Injectables |
$30.00 |
$60.00 |
| 93212091 |
Certain expensive brand name drugs (see list) |
$30.00 |
$60.00 |
|
| Group Number |
Type of Drug |
Retail Copayment |
Mail Order Copayment |
| 93212320 |
Generic |
$10.00 |
$30.00 |
| 93212320 |
Brand Name |
$30.00 |
$60.00 |
| 93212320 |
Brand Name Injectables |
$50.00 |
$100.00 |
| 93212320 |
Certain expensive brand name drugs (see list) |
$50.00 |
$100.00 |
|