Sleep Study (In-Home) Sterilization Procedures and Follow-up Testing. (Male or Female) No Charge No adjustment Wigs (Limited to2 per lifetime following Biologic, Genetic, Chemo or Radiation therapy.) Standard Benefit (30-Day Supply) Tier 1- Preferred Generic After Deductible is Met, $5 Copayment No adjustment Tier 2 - Preferred Brand After Deductible is Met, then $40 Copayment No adjustment Tier 3 - Non-Preferred Brand After Deductible is Met, then $80 Copayment No adjustment Tier 4 - Specialty Drugs After Deductible is Met, then $250 Copayment Contact Rescrybe at 866-401-1883 Prescription Drugs Standard Benefit $150 copayment per study Collaborative Care may be able to reduce member cost share $250 Copayment per wig purchased No adjustment