Page 82 - Appendices to Jane Miller's evaluation

Initial coverage Gap coverage
Tiers Catastrophic coverage phase
phase phase 1

Preferred
$0.00 copay
Generic
Generic drugs:
Generic $10.00 copay $10.00 copay $3.70 copay or 5% (whichever costs
more)
Preferred Brand $47.00 copay
Brand-name drugs:
Non-Preferred $9.20 copay or 5% (whichever costs
$100.00 copay
Drug more)

Specialty Tier 33%

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.

PART B DRUGS

Chemotherapy drugs
In-network: 20% coinsurance
Out-of-network: 40% coinsurance

Limits apply

Other Part B drugs
In-network: 20% coinsurance

Out-of-network: 40% coinsurance

Limits apply

Star ratings

OVERALL STAR RATING

HEALTH PLAN STAR RATINGS