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Pharmacy Copayments

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ProgramPlan LevelFormulary CopayFormulary CopayNon-Formulary CopayNon-Formulary Copay
Less than or equal to 30-day supply Greater than or equal to 31-day supply Less than or equal to 30-day supply Greater than or equal to 31-day supply
MAPCBRACKFQ-H$0$0$0$0
CBRACKFQ$7$14$10$20
MAP BASICBASIC 000$0$0$0$0
BASIC 100$7$10$14$20
BASIC 150$8$13$16$26
BASIC 175$9$14$18$28
BASIC 200$10$15$20$30
MAP DentalCHAPNot a CHAP BenefitNot a CHAP BenefitNot a CHAP BenefitNot a CHAP Benefit

*Provider organizations may offer pharmacy copay discounts