North Texas and Texoma Prescription Drug Benefit Overview

2024 – Cooke, Deaf Smith, Fannin, Gray, Grayson, Moore, Potter and Randall County Drug Benefits

Standard Retail Cost-Sharing — 30-day Supply

	Plus Plan	Giveback Plan
Prescription Drug Deductible	No Deductible	$300 – applies to tiers 3, 4, & 5 only
Tier 1: Preferred Generic	$0	$0
Tier 2: Generic	$12	$12
Tier 3: Preferred Brand	$35	$35
Tier 4: Non Preferred Drugs	$100	$100
Tier 5: Specialty Drugs	33%	28%
Tier 6: Specialty Drugs	$0	$0
Gap Coverage	Tiers 1, 2 & 6	Tiers 1, 2 & 6

Prescriptions are also available in a 100-day supply at two copays, and through mail order.

Standard Retail Cost-Sharing — 30-day Supply

Prescription Drug Deductible
No Deductible

Tier 1: Preferred Generic
$0

Tier 2: Generic
$12

Tier 3: Preferred Brand
$35

Tier 4: Non Preferred Drugs
$100

Tier 5: Specialty Drugs
33%

Tier 6: Specialty Drugs
$0

Gap Coverage
Tiers 1, 2 & 6

Prescription Drug Deductible
$300 – applies to tiers 3, 4, & 5 only

Tier 1: Preferred Generic
$0

Tier 2: Generic
$12

Tier 3: Preferred Brand
$35

Tier 4: Non Preferred Drugs
$100

Tier 5: Specialty Drugs
28%

Tier 6: Specialty Drugs
$0

Gap Coverage
Tiers 1, 2 & 6

Prescriptions are also available in a 100-day supply at two copays, and through mail order.

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 $70
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

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Last update 9/9/2022