HDHP PPO Retail Prescriptions: $10 $10 Tier 1: Generic Retail Prescriptions: $35 $35 Tier 2: Preferred Retail Prescriptions: $75 $75 Tier 3: Non-Preferred Retail Prescriptions: 25% coinsurance (up to $350) 25% coinsurance (up to $350) Tier 4: Specialty Mail-Order Prescriptions: $25 $25 Tier 1: Generic Mail-Order Prescriptions: $105 $105 Tier 2: Preferred Mail-Order Prescriptions: $225 $225 Tier 3: Non-Preferred Mail-Order Prescriptions: 25% coinsurance (up to $350) 25% coinsurance (up to $350) Tier 4: Specialty All retail prescriptions out-of-network are 50% coinsurance, mail-order out-of-network are not covered.