Page 65 - APPENDICES for Diane Falten

Initial coverage Gap coverage Catastrophic coverage
phase phase phase

Generic drugs:
Generic drugs:
25% $3.95 copay or 5% (whichever
Preferred costs more)
$2.00 copay
Generic Brand-name Brand-name drugs:
drugs: $9.85 copay or 5% (whichever
25%
costs more)

Generic drugs:
Generic drugs:
$3.95 copay or 5% (whichever
25%
costs more)
Generic $9.00 copay
Brand-name
Brand-name drugs:
drugs:
$9.85 copay or 5% (whichever
25%
costs more)

Generic drugs:
Generic drugs: $3.95 copay or 5% (whichever
25%
Preferred costs more)

Brand $47.00 copay Brand-name Brand-name drugs:
drugs: $9.85 copay or 5% (whichever

25%
costs more)

Generic drugs:
Generic drugs:
$3.95 copay or 5% (whichever
25%
Non-Preferred $100.00 copay costs more)
Drug Brand-name Brand-name drugs:
drugs:
$9.85 copay or 5% (whichever
25%
costs more)