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Pharmacy Co-payments Effective May 1, 2014


Please be advised that pharmacy co-payments will change as of May 1, 2014. Co-payments will once again be assessed on the total allowed charge for the prescription, regardless of preferred or non-preferred status.

The table below displays the new co-payment structure. All member categories previously excluded from co-pays will continue to be excluded.

Total Allowed Charge










$50.01 and above


Beginning April 1, 2014, members will have a maximum out-of-pocket payment. The most the member will be required to pay for prescription drugs is displayed in the table below.

Tier Level and Federal Poverty Level (FPL)

Maximum Out-of-Pocket per Household

1 (Below 50% of FPL)


2 (50.01%-100% of FPL)


3 100.01%-150% of FPL)


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