Page 56 - Appendices for Eric Hartman

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

Generic drugs:
$4.15 copay or 5% (whichever

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

$10.35 copay or 5% (whichever
costs more)

Generic drugs:
$4.15 copay or 5% (whichever
costs more)
Generic $0.00 copay —
Brand-name drugs:
$10.35 copay or 5% (whichever
costs more)

Generic drugs:

$4.15 copay or 5% (whichever
Preferred costs more)

Brand $30.00 copay —
Brand-name drugs:
$10.35 copay or 5% (whichever

costs more)

Generic drugs:
$4.15 copay or 5% (whichever
Non- costs more)
Preferred $95.00 copay —
Drug Brand-name drugs:
$10.35 copay or 5% (whichever
costs more)

[1] For all other drugs, you pay 25% for generic drugs and 25% for brand-name drugs.