Page 170 - Cover Letter and Evaluation for Gary Janke

10/8/2018 Your Medicare Health Plan Details
Eyeglass lenses Not covered

Upgrades Not covered

Optional Supplemental Benefits

None Available

Drug Plan Information
Outpatient Prescription
Drugs
Monthly Premium $59.30
Deductible $0
Formulary Website View formulary website 
Initial Coverage Phase
Tier 1 Preferred Generic
1-Month: $1.00 copay
3-Month: $1.00 copay
All: Not Available

Tier 2 Generic
1-Month: $5.00 copay
3-Month: $5.00 copay
All: Not Available
Tier 3 Preferred Brand
1-Month: $28.00 copay
3-Month: $70.00 copay
All: Not Available

Tier 4 Non-Preferred Drug
1-Month: $65.00 copay
3-Month: $165.00 copay
All: Not Available

Tier 5 Specialty Tier
1-Month: 33%
3-Month: Not Available
All: Not Available

Gap Coverage Phase
Tier 1 Preferred Generic
1-Month: $1.00 copay
3-Month: $1.00 copay
All: Not Available

Tier 3 Preferred Brand) *
1-Month: $28.00 copay
3-Month: $70.00 copay
All: Not Available

* The above cost-sharing only applies to some drugs on this tier. For all other drugs, you pay 37% for generic drugs and 25% for
brand-name drugs.

Catastrophic Coverage
Phase
Generic drugs Generic drugs
$3.40 copay or 5% (whichever costs more)
Brand-name drugs Brand-name drugs
$8.50 copay or 5% (whichever costs more)

https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H7917&plnid=013&sgmntid=0#plan_benefits 5/6