Bayview DPC Plan — 2023
Prescription Services and Supplies
Sorry, no results.
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 |
Preferred | $40 | $120 | $80 |
Non-Preferred | $65 | $195 | $130 |
Prescription Drugs | |||
Generic | $10 | $30 | $20 |
Preferred | $40 | $120 | $80 |
Non-Preferred | $65 | $195 | $130 |
Brand with Generic Equivalent | $65 plus the cost differential between generic and brand | $195 plus the cost differential between generic and brand | $130 plus the cost differential between generic and brand |
Specialty Medications | Refer to Preferred/Non-Preferred Brand | Restricted to a 30-day retail supply only | Restricted to a 30-day retail supply only |
Revised
October 2, 2023
Group Number
E0000600, E0000700, E0016100
Plan Codes
Under $50K: JD1C0000; $50K to $120K: JD3C0000; $120K and over: JD5C0000