Copayments and annual out-of-pocket maximums. For each year of the contract: Formulary copayment: Fifteen dollar ($15) copayment per prescription or refill for a formulary drug dispensed in a thirty-four (34) day supply. Non-formulary copayment: Thirty dollar ($30) copayment per prescription or refill for a non-formulary drug dispensed in a thirty-four (34) day supply. Out-of-pocket maximum: There is an annual maximum eligible out-of-pocket expense limit for prescription drugs of six hundred fifty dollars ($650) per person or one thousand three hundred dollars ($1,300) per family.
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