Page 57 - Evaluation for 2018

1/3/2018 Your Medicare Health Plan Details
Drug Plan Information

Outpatient Prescription Drugs

Monthly Premium $0.00
Deductible $180
Formulary Website View formulary website 
Initial Coverage Phase
Tier 1 Preferred Generic
1-Month: $4.00 copay
3-Month: $12.00 copay
All: Not Available
Tier 2 Generic
1-Month: $15.00 copay
3-Month: $45.00 copay
All: Not Available

Tier 3 Preferred Brand
1-Month: $47.00 copay
3-Month: $141.00 copay
All: Not Available

Tier 4 Non-Preferred Drug
1-Month: $100.00 copay
3-Month: $300.00 copay
All: Not Available

Tier 5 Specialty Tier
1-Month: 29%
3-Month: Not Available
All: Not Available

After you pay your deductible, if applicable, up to the initial coverage limit of $3,750
Coverage Gap Phase
Generic drugs Generic drugs
44%
Brand-name drugs Brand-name drugs
35%
After the total drug costs paid by you and the plan reach $3,750, up to the out-of-pocket threshold of $5,000
Catastrophic Coverage Phase

Generic drugs Generic drugs
Greater of 5% or $3.35 copay
Brand-name drugs Brand-name drugs
Greater of 5% or $8.35 copay
When your annual out-of-pocket costs exceed $5,000

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