PPO PLAN A PPO PLAN B HDHP C HDHP D Retail Prescriptions: Greater of $10 or 15% $10 copay Deductible + coinsurance Deductible + coinsurance Tier 1: Generic Retail Prescriptions: Greater of $40 or 40% Greater of $40 or 40% Deductible + coinsurance Deductible + coinsurance Tier 2: Formulary Retail Prescriptions: Greater of $60 or 60% Greater of $60 or 60% Deductible + coinsurance Deductible + coinsurance Tier 3: Non-Formulary Retail Prescriptions: 10% of prescription cost after 20% of prescription cost after Deductible + coinsurance Deductible + coinsurance Specialty deductible deductible Mail Order Prescriptions: 10% 10% of cost Deductible + coinsurance Deductible + coinsurance Tier 1: Generic Mail Order Prescriptions: Greater of $40 or 40% Greater of $40 or 40% Deductible + coinsurance Deductible + coinsurance Tier 2: Formulary Mail Order Prescriptions: Greater of $60 or 60% Greater of $60 or 60% Deductible + coinsurance Deductible + coinsurance Tier 3: Non-Formulary Mail Order Prescriptions: 10% of prescription cost 20% of prescription cost Deductible + coinsurance Deductible + coinsurance Specialty Out-of-Network Plan A & B Retail prescriptions: copay + difference in cost. Specialty prescriptions: same in or out of network. Mail order: not covered. Out-of-Network Plan C and D not covered.