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Important Message About What You Pay for Vaccines - Our plan covers most Part D vaccines at no cost to you. Call Member Services for more information.

Important Message About What You Pay for Insulin - You won't pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it's on, even if you haven't paid your deductible.

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[PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply [LD] = Limited Distribution
You can find information on what the symbols and abbreviations on this table mean by going to page XX.
Should you have any questions, please contact Member Experience at 1-888-257-5776

Formulary Effective Date: 01/01/2025

Updated:

10/2024

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