Page 189 - Cover Letter and Evaluation for Sue Marx

2/7/2019 Your Medicare Health Plan Details

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: $10.00 copay
3-Month: $20.00 copay
All: Not Available
Tier 3 Preferred Brand
1-Month: $42.00 copay
3-Month: $105.00 copay
All: Not Available

Tier 4 Non-Preferred Drug
1-Month: 45%
3-Month: 45%
All: Not Available

Tier 5 Specialty Tier
1-Month: 33%
3-Month: Not Available
All: Not Available

Gap Coverage Phase
Generic drugs Generic drugs
37%
Brand-name drugs Brand-name drugs
25%
Catastrophic Coverage
Phase
Generic drugs Generic drugs
$3.40 copay or 5% (whichever costs more)
Brand-name drugs Brand-name drugs
$8.50 copay or 5% (whichever costs more)

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