Page 52 - APPENDICES for Vic Bosiger

Initial coverage Gap coverage Catastrophic coverage
phase phase phase

Generic drugs:
Generic drugs:
25% $3.95 copay or 5% (whichever
costs more)
Specialty Tier 30%
Brand-name Brand-name drugs:
drugs: $9.85 copay or 5% (whichever
25%
costs more)