Prescription Plan. Effective 7/1/18, the HMO prescription plan will revert 8 to a three (3) system by the provider. Retail co-pay per thirty (30) day 9 prescription: $5 generic; $10 formulary; and $35 non-formulary. Mail order 10 co-pay for up to ninety (90) day prescription supply: $5 generic; $10 11 formulary; and $35 non-formulary. 12
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Prescription Plan. Effective 7/1/18, the HMO prescription plan will revert 8 18 to a three (3) system by the provider. Retail co-pay per thirty (30) day 9 19 prescription: $5 generic; $10 formulary; and $35 non-formulary. Mail order 10 co-pay 20 for up to ninety (90) day prescription supply: $5 generic; $5 generic, $10 11 21 formulary; and $35 non-non formulary. 1222
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Prescription Plan. Effective 7/1/18, the HMO prescription plan will revert 8 18 to a three (3) system by the provider. Retail co-pay per thirty (30) day 9 19 prescription: $5 generic; $10 formulary; and $35 non-formulary. Mail order 10 co-pay 20 for up to ninety (90) day prescription supply: $5 generic; $5 generic, $10 11 21 formulary; and $35 non-formulary. 1222
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Samples: Agreement
