Page 106 - Appendices to Heidi Bathon's Evaluation

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

Generic drugs:
$3.95 copay or 5% (whichever costs
more)
Preferred Generic $5.00 copay —
Brand-name drugs:
$9.85 copay or 5% (whichever costs
more)

Generic drugs:
$3.95 copay or 5% (whichever costs
more)
Generic $10.00 copay $10.00 copay
Brand-name drugs:
$9.85 copay or 5% (whichever costs
more)

Generic drugs:
$3.95 copay or 5% (whichever costs
more)
Preferred Brand $45.00 copay —
Brand-name drugs:
$9.85 copay or 5% (whichever costs
more)

Generic drugs:
$3.95 copay or 5% (whichever costs
more)
Non-Preferred 40% —
Drug Brand-name drugs:

$9.85 copay or 5% (whichever costs
more)

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] * The above cost-sharing only applies to some drugs on this tier. For all other drugs, you pay 25% for generic drugs and 25%
for brand-name drugs.