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Pharmacy Copayments
| Program | Plan Level | Formulary Copay | Formulary Copay | Non-Formulary Copay | Non-Formulary Copay |
|---|---|---|---|---|---|
| Less than or equal to 30-day supply | Greater than or equal to 31-day supply | Less than or equal to 30-day supply | Greater than or equal to 31-day supply | ||
| MAP | MAP 000 | $0 | $0 | $0 | $0 |
| MAP 100 | $7 | $14 | $10 | $20 | |
| MAP BASIC | BASIC 000 | $0 | $0 | $0 | $0 |
| BASIC 100 | $7 | $14 | $10 | $20 | |
| BASIC 150 | $8 | $16 | $13 | $26 | |
| BASIC 175 | $9 | $18 | $14 | $28 | |
| BASIC 200 | $10 | $20 | $15 | $30 | |
| MAP BASIC – DENTAL ONLY | CUC 000 | $0 | $0 | $0 | $0 |
| CUC 100 | $7 | $14 | $10 | $20 | |
| CUC 150 | $8 | $16 | $13 | $26 | |
| CUC 175 | $9 | $18 | $14 | $28 | |
| CUC 200 | $10 | $20 | $15 | $30 |
*Provider organizations may offer pharmacy copay discounts