BlueSelect 2139
Preferred Brand: $200 Copay per Prescription (retail) Not Covered Up to 30 day supply for retail, 90 day supply for mail order at 2 1/2 times the retail amount. Non-preferred brand drugs $5,500 Pharmacy Deductible + 50% Coinsurance (retail) Not Covered Up to 30 day supply for retail, 90 day supply for mail order at 2 1/2 times the retail amount.
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