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HCGH EPO Plan — 2023

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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
Preferred 25%; $40 min; $60 max 25%; $120 min; $180 max 25%; $120 min; $180 max
Non-Preferred 50%; $65 min; $105 max 50%; $195 min; $315 max 50%; $195 min; $315 max
Prescription Drugs
Generic $10 $30 $30
Preferred 25%; $40 min; $60 max 25%; $120 min; $180 max 25%; $120 min; $180 max
Non-Preferred 50%; $65 min; $105 max 50%; $195 min; $315 max 50%; $195 min; $315 max
Brand with Generic Equivalent 50%; $65 min; $105 max, plus the cost differential between generic and brand 50%; $195 min; $315 max, plus the cost differential between generic and brand 50%; $195 min; $315 max, plus the cost differential between generic and brand
Revised
October 2, 2023
Group Number
E0008000
Plan Codes
JE1C0000
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