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2024 Johns Hopkins EPO Plan

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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
Specialty Medications for members enrolled in Prudent RX – medications listed at ehp.org $0 Restricted to a 30-day retail supply only Restricted to a 30-day retail supply only
Specialty Medications for members not enrolled in Prudent RX – medications listed at ehp.org 30% Restricted to a 30-day retail supply only Restricted to a 30-day retail supply only
Revised
August 26, 2024
Plan Codes
JE1C0000
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