Base Plan Buy-Up Plan Surest Plan Retail Pharmacy: You pay $0 You pay $0 N/A Preventive Retail Pharmacy Tier One: Deductible, then $0 copay Deductible, then $0 copay $0 copay (30-day supply) Generic Retail Pharmacy Tier Two: Deductible, then $0 copay Deductible, then $0 copay $0 copay (30-day supply) Brand Name Formulary Retail Pharmacy Tier Three: Deductible, then $0 copay Deductible, then $0 copay $0 copay (30-day supply) Brand Name Non-Formulary Retail Pharmacy Tier Four: Deductible, then 15% max $0 Deductible, then 25% max $200 N/A Specialty Medication Mail Order Tier One: Deductible, then $0 copay Deductible, then $0 copay $25 copay (90-day supply) Generic Mail Order Tier Two: Deductible, then $5 copay Deductible, then $0 copay $0 copay (90-day supply) Brand Name Formulary Mail Order Tier Three: Deductible, then $0 copay Deductible, then $0 copay $0 copay (90-day supply) Brand Name Non-Formulary Mail Order Tier Four: Deductible, then 15% max $0 Deductible, then 25% max $0 $0 - $0 copay Specialty Medication Retail pharmacy is a 30-day supply, mail-order is a 90-day supply. Specialty medications are limited to a 30-day supply, regardless of whether they are retail or mail order. The Preventive Drug Plan is an in-network benefit that covers preventive drugs at 100% for the base and buy-up HDHP plans. For UMR HDHP plan members, any preventive drug purchased, which is not on the UMR Preventive Drug List, will have the deductible and coinsurance applied. Please refer to the Preventive Drug List for a complete listing of drugs covered under this benefit.