Page 51 - APPENDICES for Vic Bosiger
P. 51
Initial coverage Gap coverage Catastrophic coverage
phase phase phase
Generic drugs:
Generic drugs:
25% $3.95 copay or 5% (whichever
Preferred costs more)
$0.00 copay
Generic Brand-name Brand-name drugs:
drugs: $9.85 copay or 5% (whichever
25%
costs more)
Generic drugs:
Generic drugs:
$3.95 copay or 5% (whichever
25%
costs more)
Generic $10.00 copay
Brand-name
Brand-name drugs:
drugs:
$9.85 copay or 5% (whichever
25%
costs more)
Generic drugs:
Generic drugs: $3.95 copay or 5% (whichever
25%
Preferred costs more)
Brand $42.00 copay Brand-name Brand-name drugs:
drugs: $9.85 copay or 5% (whichever
25%
costs more)
Generic drugs:
Generic drugs:
$3.95 copay or 5% (whichever
25%
Non-Preferred $95.00 copay costs more)
Drug Brand-name Brand-name drugs:
drugs:
$9.85 copay or 5% (whichever
25%
costs more)
