Page 27 - APPENDICES for Vic Bosiger

Initial coverage Gap coverage Catastrophic coverage
phase phase [ 1 ] phase

Generic drugs:
$3.95 copay or 5% (whichever

Preferred costs more)
$0.00 copay $0.00 copay
Generic Brand-name drugs:

$9.85 copay or 5% (whichever
costs more)

Generic drugs:
$3.95 copay or 5% (whichever
costs more)
Generic $14.00 copay $14.00 copay
Brand-name drugs:
$9.85 copay or 5% (whichever
costs more)

Generic drugs:

$3.95 copay or 5% (whichever
Preferred costs more)

Brand $47.00 copay —
Brand-name drugs:
$9.85 copay or 5% (whichever

costs more)

Generic drugs:
$3.95 copay or 5% (whichever
Non- costs more)
Preferred $100.00 copay —
Drug Brand-name drugs:
$9.85 copay or 5% (whichever
costs more)

[1] * The above cost-sharing only applies to some drugs on this tier. For all other drugs, you pay 25% for

generic drugs and 25% for brand-name drugs.