Retail Prescriptions: Tier 1: Generic $35 $35 after deductible deductible + coinsurance Retail Prescriptions: Tier 2: Preferred $65 $65 after deductible deductible + coinsurance Retail Prescriptions: Tier 3: Non-Preferred $100 $100 after deductible deductible + coinsurance Retail Prescriptions: Tier 4: Specialty $200 $200 after deductible deductible + coinsurance Mail Order Prescriptions: Tier 1: Generic $70 $70 after deductible deductible + coinsurance Mail Order Prescriptions: Tier 2: Preferred $130 $130 after deductible deductible + coinsurance Mail Order Prescriptions: Tier 3: Non-Preferred $200 $200 after deductible deductible + coinsurance Mail Order Prescriptions: Tier 4: Specialty $400 $400 after deductible deductible + coinsurance PPO PLAN HSA PLAN ONE HSA PLAN TWO Out-of-Network prescriptions are not covered.