Page 31 - Cover letter and evaluation for Peter Smith

11/27/2017 Your Medicare Health Plan Details
Optional Supplemental Benefits

Package #1 Comprehensive dental services, Preventive dental services
Monthly Premium $35.00
Deductible N/A

Drug Plan Information
Outpatient Prescription Drugs
Monthly Premium $0.00
Deductible $0
Formulary Website View formulary website 
Initial Coverage Phase
Tier 1 Preferred Generic
1-Month: $0.00 copay
3-Month: $0.00 copay
All: Not Available

Tier 2 Generic
1-Month: $7.50 copay
3-Month: $22.50 copay
All: Not Available
Tier 3 Preferred Brand
1-Month: $40.00 copay
3-Month: $120.00 copay
All: Not Available

Tier 4 Non-Preferred Drug
1-Month: $85.00 copay
3-Month: $255.00 copay
All: Not Available

Tier 5 Specialty Tier
1-Month: 33%
3-Month: Not Available
All: Not Available
Tier 6 Select Care Drugs
1-Month: $0.00 copay
3-Month: $0.00 copay
All: Not Available

After you pay your deductible, if applicable, up to the initial coverage limit of $3,750
Coverage Gap Phase

Tier 1 Preferred Generic
1-Month: $0.00 copay
3-Month: $0.00 copay
All: Not Available
Tier 2 Generic
1-Month: $7.50 copay
3-Month: $22.50 copay
All: Not Available

Tier 6 Select Care Drugs
1-Month: $0.00 copay
3-Month: $0.00 copay
All: Not Available

All drugs may not be offered with additional gap coverage, for all other drugs, you pay 44% for generic drugs and 35% for brand-
name drugs.
After the total drug costs paid by you and the plan reach $3,750, up to the out-of-pocket threshold of $5,000

https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H4346&plnid=001&sgmntid=0 4/5