Plan 1 Plan 2 Plan 3 Preventive Prescriptions $0 $0 $0 Retail Prescriptions: Tier 1 $15 Copay Deductible + coinsurance Deductible + coinsurance Retail Prescriptions: Tier 2 $15 Copay Deductible + coinsurance Deductible + coinsurance Retail Prescriptions: Tier 3 $30 Copay Deductible + coinsurance Deductible + coinsurance Retail Prescriptions: Tier 4 $60 Copay Deductible + coinsurance Deductible + coinsurance Specialty Prescription Drugs: (Self Administered) 20% after deductible (up to $350 Maximum) Deductible + coinsurance Deductible + coinsurance Mail Order Prescriptions: (Tier 1/ Tier 2/ Tier 3/ Tier 4) $45/$45/$90/$180 Deductible + coinsurance Deductible + coinsurance