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Johns Hopkins Hospital/Johns Hopkins Health System Corporation 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
December 1, 2022
Group Number
E0009000, E0009100, E0009200, E0009300, E0019000, E0019200, E0019400, E0019800
Plan Codes
JE1C0000
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