USC PPO Plan – Copays

Patient Pay Standard Retail Network:

30 Day: Tier 1 $10/ Tier 2 $25/ Tier 3 $70
60 Day: Tier 1 $20/Tier 2 $50/ Tier 3 $140
90 Day: Tier 1 $30/ Tier 2 $75/ Tier 3$210

Patient Pay Custom Network (in-house pharmacies only):

30 Day: Tier 1 $5/ Tier 2 $15/ Tier 3 $35
60-90 Day: Tier 1 $10/ Tier 2 $30/ Tier 3 $70

Mail Order:

30 Day: Tier 1 $10/ Tier 2 $25/ Tier 3 $70
60-90 Days: Tier 1 $20/ Tier 2 $50/ Tier 3 $140

Specialty:

All Tiers: $125.00

Patient Pay Standard Retail Network:

30 Day: Tier 1 $10/ Tier 2 $25/ Tier 3 $70
60 Day: Tier 1 $20/Tier 2 $50/ Tier 3 $140
90 Day: Tier 1 $30/ Tier 2 $75/ Tier 3$210

Patient Pay Custom Network (in-house pharmacies only):

30Day: Tier 1 $10/ Tier 2 $25/ Tier 3 $40
60-90 Day: Tier 1 $20/ Tier 2 $50/ Tier 3 $80

Mail Order:

30 Day: Tier 1 $10/ Tier 2 $25/ Tier 3 $70
60-90 Days: Tier 1 $25/ Tier 2 $62.50/ Tier 3 $175

Specialty:

All Tier: $125.00