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Plan guide 2022

Jan 01, 2022 · In-Network Out-of-Network *Benefits are combined in and out-of-network Prescription Drugs Your Cost Initial Coverage Stage Network Pharmacy (30 -day retail supply) Mail Service Pharmacy (90-day supply) Tier 1: Preferred Generic $0 copay $0 copay Tier 2: Generic $ 4 copay $ 4 copay Tier 3: Preferred Brand $ 40 copay $ 100 copay

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  Network, Pharmacy, Pharmacy network, In network

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