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Pharmacy Copayments
Program | Plan Level | Formulary Copay | Formulary Copay | Non-Formulary Copay | Non-Formulary Copay |
---|---|---|---|---|---|
Less than or equal to 30-day supply | Greater than or equal to 31-day supply | Less than or equal to 30-day supply | Greater than or equal to 31-day supply | ||
MAP | MAP 000 | $0 | $0 | $0 | $0 |
MAP 100 | $7 | $14 | $10 | $20 | |
MAP BASIC | BASIC 000 | $0 | $0 | $0 | $0 |
BASIC 100 | $7 | $14 | $10 | $20 | |
BASIC 150 | $8 | $16 | $13 | $26 | |
BASIC 175 | $9 | $18 | $14 | $28 | |
BASIC 200 | $10 | $20 | $15 | $30 | |
MAP BASIC – DENTAL ONLY | CUC 000 | $0 | $0 | $0 | $0 |
CUC 100 | $7 | $14 | $10 | $20 | |
CUC 150 | $8 | $16 | $13 | $26 | |
CUC 175 | $9 | $18 | $14 | $28 | |
CUC 200 | $10 | $20 | $15 | $30 |
*Provider organizations may offer pharmacy copay discounts