2021 South Texas Prescription Drug Benefits2020-08-27T11:02:36-04:00

South Texas

Brooks, Hidalgo and Starr 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