Your drug benefit

If you have prescription drug coverage, your drug rider explains what medications are covered. It also lists your copayment as a dollar amount or as a percentage of the total prescription cost and indicates when the copayment applies.

Select a drug rider from the left column in the table below to learn more about your drug coverage. Contact Customer Service at 800-662-6667 if you don't know your drug rider or if your drug rider does not appear on this list.

Prescription drug riders Required copayment
Formulary Nonformulary
Drug rider Type Tier 1 Tier 2 Tier 3
$0 Flat $0 $0 $0
$2 Flat $2 $2 $2
$3 Flat $3 $3 $3
$4 Flat $4 $4 $4
$5 Flat $5 $5 $5
$7 Flat $7 $7 $7
$10 Flat $10 $10 $10
$15 Flat $15 $15 $15
$20 Flat $20 $20 $20
$5/$7 2-Tier Closed $5 $7 Not covered
$5/$10 2-Tier Closed $5 $10 Not covered
$5/$11 ($16) 2-Tier Open $5 $11 $11
$5/$11 ($16) 2-Tier Closed $5 $11 Not covered
$5/$15 2-Tier Closed $5 $15 Not covered
$5/$20 2-Tier Closed $5 $20 Not covered
$5/$25 2-Tier Closed $5 $25 Not covered
$5/$30 2-Tier Closed $5 $30 Not covered
$5/$35 2-Tier Closed $5 $35 Not covered
$5/$40 2-Tier Closed $5 $40 Not covered
$5/$50 2-Tier Closed $5 $50 Not covered
$7/$15 2-Tier Closed $7 $15 Not covered
$7/$20 2-Tier Closed $7 $20 Not covered
$10/$15 2-Tier Closed $10 $15 Not covered
$10/$20 2-Tier Closed $10 $20 Not covered
$10/$25 2-Tier Closed $10 $25 Not covered
$10/$30 2-Tier Closed $10 $30 Not covered
$10/$40 2-Tier Closed $10 $40 Not covered
$15/$25 2-Tier Closed $15 $25 Not covered
$15/$30 2-Tier Closed $15 $30 Not covered
$15/$35 2-Tier Closed $15 $35 Not covered
$15/$50 2-Tier Closed $15 $50 Not covered
$20/$60 2-Tier Closed $20 $60 Not covered
$15/40% 2-Tier Closed $15 40% Not covered
$5/$10 (open) 2-Tier Open $5 $10 $10
$5/$15 (open) 2-Tier Open $5 $15 $15
$7/$15 (open) 2-Tier Open $7 $15 $15
$10/$40(open) 2-Tier Open $10 $40 $40
$15/$50(open) 2-Tier Open $15 $50 $50
$3/$12/$25 3-Tier $3 $12 $25
$5/$10/20% 3-Tier $5 $10 20%
$5/$10/$15 3-Tier $5 $10 $15
$5/$10/$20 3-Tier $5 $10 $20
$5/$10/$30 3-Tier $5 $10 $30
$5/$15/$25 3-Tier $5 $15 $25
$5/$20/$30 3-Tier $5 $20 $30
$5/$30/$60 3-Tier $5 $30 $60
$7/$15/$30 3-Tier $7 $15 $30
$7/$20/$35 3-Tier $7 $20 $35
$10/$15/$30 3-Tier $10 $15 $30
$10/$20/$30 3-Tier $10 $20 $30
$10/$25/$40 3-Tier $10 $25 $40
$10/$20/$40 3-Tier $10 $20 $40
$10/$25/$50 3-Tier $10 $25 $50
$10/$30/$60 3-Tier $10 $30 $60
$10/30%/45% 3-Tier $10 30% 45%
$15/$30/$60 3-Tier $15 $30 $60
$15/$50/50% 3-Tier $15 $50 50%
$20/$60/50% 3-Tier $20 $60 50%
25%/35%/45% 3-Tier 25% 35% 45%
20% Percentage 20% 20% 20%
30% Percentage 30% 30% 30%
50% Percentage 50% 50% 50%

page modified 02/19/2009