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Howard County General Hospital EPO Plan — 2022

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In-Network Retail Pharmacy (30-day supply)In-Network Retail Pharmacy (90-day supply)Mail Order (90-day supply)
Oral Contraceptives
Generic$0$0$0
Preferred25%; $40 min; $60 max25%; $120 min; $180 max25%; $120 min; $180 max
Non-Preferred50%; $65 min; $105 max50%; $195 min; $315 max50%; $195 min; $315 max
Prescription Drugs
Generic$10$30$30
Preferred25%; $40 min; $60 max25%; $120 min; $180 max25%; $120 min; $180 max
Non-Preferred50%; $65 min; $105 max50%; $195 min; $315 max50%; $195 min; $315 max
Brand with Generic Equivalent50%; $65 min; $105 max, plus the cost differential between generic and brand50%; $195 min; $315 max, plus the cost differential between generic and brand50%; $195 min; $315 max, plus the cost differential between generic and brand
Revised
September 15, 2022
Group Number
E00080
Plan Codes
JE1
Available 24/7

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