Broadway Plan — 2024 – 2025
Prescription Services and Supplies
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| In-Network Retail Pharmacy (30-day supply) | In-Network Retail Pharmacy (90-day supply) | Mail Order (90-day supply) | |
|---|---|---|---|
| Oral Contraceptives | |||
| Generic | Not Covered | Not Covered | Not Covered |
| Preferred Brand | Not Covered | Not Covered | Not Covered |
| Non-Preferred Brand | Not Covered | Not Covered | Not Covered |
| Prescription Drugs | |||
| Generic | $10 | $30 | $20 |
| Preferred Brand | $20 | $60 | $40 |
| Non-Preferred Brand | $30 | $90 | $60 |
Revised
November 27, 2024
Group Number
E0000800, E0000900
Plan Codes
112C0000, 603C0000
