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Pharmacy Copayments

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ProgramPlan LevelFormulary CopayFormulary CopayNon-Formulary CopayNon-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
MAPMAP 000$0$0$0$0
MAP 100$7$14$10$20
MAP BASICBASIC 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 ONLYCUC 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