USC PPO Plan – Copays

Retail Drug Copays – Network Pharmacy:

(Per 30-day supply)

• Generic: $5 Copay
• Preferred: $25 Copay
• Non-Preferred: $70 Copay
• Specialty Drug (Brand): $125 Copay

 Note: Mail Order available at the same Copays as Retail, for each 30-day supply

Retail Drug Copay – Non-Network Pharmacy:

(Per 30-day supply)

• Plan reimburses you 50% of the Optum contracted rate (not of cost)