Examples of Tier 5 in a sentence
Tier 4: $100 Not Covered Tier 5: $150 Not Covered When purchased at a Retail Pharmacy (+): For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribed dosing period.
Tier 1 Preventive: $0 Tier 1 Non-preventive: $10 Not Covered Tier 2 Preventive: $0 Tier 2 Non-preventive: $35 Not Covered Tier 3: $70 Not Covered Tier 4 and Tier 5: NRT and Smoking Cessation drugs are only placed in Tier 1, Tier 2, or Tier 3.
When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% Not Covered Tier 2: 20% Not Covered Tier 3: 20% up to $150 Not Covered When purchased at a Specialty Pharmacy (+) Tier 4: 20% up to $150 Not Covered Tier 5: 20% Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy may require a higher out of pocket expense than if purchased from a Specialty Pharmacy.
Tier 1: $10 Not Covered Tier 2: $35 Not Covered Tier 3: $70 Not Covered Tier 4 and Tier 5: See specialty prescription drug section below.
Tier 4: 20% up to $150 Not Covered Tier 5: 20% up to $150 Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Contraceptive Methods - when covered as a preventive care service as described in Section 3.
Tier 1: $25 Not Covered Tier 2: $87.50 Not Covered Tier 3: $210 Not Covered Tier 4 and Tier 5: See specialty prescription drug section below.
Tier 4: 50% up to $150 Not Covered Tier 5: 50% up to $150 Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered (+) Preauthorization is required for this service.