Page 85 - APPENDICES for Fred Falten

Optional packages

This plan includes optional bene ts you can add to your coverage at an additional cost.

Package #1 Includes preventive dental services, and comprehensive dental services
Monthly premium: $26.10
Deductible: N/A

Package #2 Includes preventive dental services, and comprehensive dental services

Monthly premium: $34.90
Deductible: N/A

Drug coverage & costs

See if there's help to lower costs for drugs you take.

Plans group their drug lists into tiers. The table below shows your portion of the drug cost in certain
tiers based on which coverage phase you're in for this plan

Learn more about drug tiers

TIER DRUG COST FOR

Preferred retail pharmacy drug cost for 1-month

Initial coverage Gap coverage
Tiers Catastrophic coverage phase
phase phase

Preferred Generic $2.00 copay Generic drugs: Generic drugs:
25% $3.70 copay or 5% (whichever costs
Generic $9.00 copay
more)
Brand-name
Preferred Brand $47.00 copay
drugs: Brand-name drugs:
25% $9.20 copay or 5% (whichever costs
Non-Preferred
$100.00 copay more)
Drug