North Texas and Texoma
Cooke, Deaf Smith, Fannin, Gray, Grayson, Moore, Potter and Randall counties
Standard Retail Cost-Sharing — 30-day Supply
| Prominence Plus Plan | |
|---|---|
| Prescription Drug Deductible | No Deductible |
| Phase 1: Initial Coverage Tier 1 (Preferred Generic) |
You pay $0 |
| Tier 2 (Generic) | You pay $12 |
| Tier 3 (Preferred Brand) | You pay $35 |
| Tier 4 (Non-Preferred Drugs) | You pay $100 |
| Tier 5 (Specialty Drugs) | You pay 33% |
| Tier 6 (Selected Drugs) | You pay $0 |
| Phase 2: Coverage Gap | Tier 1, 2 and 6 drugs are covered in the gap |
Mail Order — 100-day Supply
| Prominence Plus Plan | |
|---|---|
| Prescription Drug Deductible | No Deductible |
| Phase 1: Initial Coverage Tier 1 (Preferred Generic) |
You pay $0 |
| Tier 2 (Generic) | You pay $24 |
| Tier 3 (Preferred Brand) | You pay $105 |
| Tier 4 (Non-Preferred Drugs) | You pay $300 |
| Tier 5 (Specialty Drugs) | Not available |
| Tier 6 (Selected Drugs) | You pay $0 |
| Phase 2: Coverage Gap | Tier 1, 2 and 6 drugs are covered in the gap |