Standard Plan* Premium HSA** Basic HSA**
  Retail (30-day supply) Mail Order (90-day supply) Retail (30-day supply) Mail Order (90-day supply) Retail (30-day supply) Mail Order (90-day supply)
Generic $7 Copay $15 Copay $7 Copay $15 Copay $7 Copay $15 Copay
Formulary Brand 25%
$30 min
$60 max		 25%
$75 min
$150 max		 30% 30% 30% 30%
Non-Formulary Brand 30%
$60 min
$100 max		 30%
$150 min
$250 max		 30% 30% 30% 30%
Specialty Drugs 30%
$250 max		 30%
$250 max		 30% 30% 30% 30%

*Deductible does not apply; pharmacy expenses accumulate toward medical out-of-pocket maximum.

**Deductible applies; Deductible and out-of-pocket maximum combined for medical and pharmacy expenses. Deductible does not apply to certain preventive drugs. For a list of preventive drugs, please visit www.caremark.com, or call 1-877-252-3485.