Page 103 - Appendices for Eric Hartman
P. 103
Initial coverage Gap coverage
phase phase Catastrophic coverage phase
Generic drugs:
Generic drugs:
25% $4.15 copay or 5% (whichever
Preferred costs more)
$2.00 copay
Generic Brand-name Brand-name drugs:
drugs: $10.35 copay or 5% (whichever
25%
costs more)
Generic drugs:
Generic drugs:
$4.15 copay or 5% (whichever
25%
costs more)
Generic $15.00 copay
Brand-name
Brand-name drugs:
drugs:
$10.35 copay or 5% (whichever
25%
costs more)
Generic drugs:
Generic drugs: $4.15 copay or 5% (whichever
25%
Preferred costs more)
Brand 25% Brand-name Brand-name drugs:
drugs: $10.35 copay or 5% (whichever
25%
costs more)
Generic drugs:
Generic drugs:
$4.15 copay or 5% (whichever
25%
Non-Preferred 50% costs more)
Drug Brand-name Brand-name drugs:
drugs:
$10.35 copay or 5% (whichever
25%
costs more)
