Summary of Covered Prescription Drug Benefits¹	Home Delivery Service	Retail Network Pharmacy CVS, Walmart, Sam’s Club, Smith’s²
Tier 1 — Generic	$15 copay per 34-day supply³ $40 copay per 35+ day supply³
Tier 2 — Preferred Formulary Brand	25% of the cost, copay max of $100 per 34-day supply 25% of the cost, copay max of $300 per 35+ day supply
Tier 3 — Non-Preferred Formulary Brand	40% of the cost, copay per 34-day supply 40% of the cost, copay per 35+ day supply
Formulary Diabetic Supplies	$0 copay (includes syringes needles, lancets, and test strips; limited to a quantity of 200 per 30-day supply)

Summary of Covered Prescription Drug Benefits¹	Specialty Drugs⁴ (Up to a 30-day supply)
Tier 1 — Generic	25% of the cost, up to $500 max copay
Tier 2 — Preferred Formulary Brand	25% of the cost, up to $500 max copay
Tier 3 — Non-Preferred Brand	40% of the cost, copay, per 30-day supply
(1) Select products are eligible for a coinsurance assistance program. There is no copay for these products and they do not accumulate toward the out-ofpocket maximum. For more information contact THT at 702-794-0272, Option 1. (2) Prescriptions filled at pharmacies other than THT’s Exclusive Network Retail Pharmacies will incur a $10 per prescription choice fee in addition to applicable copays. The pharmacy choice fee does not accumulate toward your outof-pocket maximum. (3) If the generic cost of the medication is less than the copay, the individual will be responsible for that lesser amount. (4) For more information about this service, please contact CerpassRX at 844-622-1797.

Summary of Covered Prescription Drug Benefits¹	Home Delivery Service	Retail Network Pharmacy CVS, Walmart, Sam’s Club, Smith’s²
Tier 1 — Generic	$15 copay after deductible per 34-day supply³ $40 copay after deductible per 35+ day supply³
Tier 2 — Preferred Formulary Brand	25% of the cost after deductible, copay max of $100 per 34-day supply 25% of the cost after deductible, copay max of $300 per 35+ day supply
Tier 3 — Non-Preferred Formulary Brand	40% of the cost after deductible, copay per 34-day supply 40% of the cost after deductible, copay per 35+ day supply
Formulary Diabetic Supplies	$0 copay after deductible (includes syringes needles, lancets, and test strips; limited to a quantity of 200 per 30-day supply)

Summary of Covered Prescription Drug Benefits¹	Specialty Drugs⁴ (Up to a 30-day supply)
Tier 1 — Generic	25% of the cost after deductible, up to $500 max copay
Tier 2 — Preferred Formulary Brand	25% of the cost after deductible, up to $500 max copay
Tier 3 — Non-Preferred Brand	40% of the cost after deductible, copay, per 30-day supply
(1) Select products are eligible for a coinsurance assistance program. There is no copay for these products and they do not accumulate toward the out-ofpocket maximum. For more information contact THT at 702-794-0272. (2) Prescriptions filled at pharmacies other than THT’s Exclusive Network Retail Pharmacies will incur a $10 per prescription choice fee in addition to applicable copays. The pharmacy choice fee does not accumulate toward your out-ofpocket maximum. (3) If the generic cost of the medication is less than the copay, the individual will be responsible for that lesser amount. (4) For more information about this service, please contact CerpassRx at 844-622-1797.

Pharmacy Coverage