Page 82 - Appendices to Donald Pender's Evaluation
P. 82
Initial coverage Gap coverage Catastrophic coverage
phase phase [ 1 ] phase
Generic drugs:
$3.95 copay or 5% (whichever
costs more)
Specialty Tier 33% —
Brand-name drugs:
$9.85 copay or 5% (whichever
costs more)
[1] For all other drugs, you pay 25% for generic drugs and 25% for brand-name drugs.
OTHER DRUG INFORMATION
Prior Quantity Step
Tier
authorization limits therapy
Dutasteride 0.5mg Tier
capsule 2 — Yes —
MY DRUG LIST
Package Quantity Frequency Brand/Generic
Dutasteride 0.5mg Every
capsule 30 month Generic
