North Texas and Texoma Prescription Drug Benefits2023-09-22T12:09:34-04:00
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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.

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

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.

2023 – Cooke, Deaf Smith, Fannin, Gray, Grayson, Moore, Potter and Randall County Drug Benefits

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

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