Page 34 - APPENDICES for Hans Burkhardt

Initial coverage Gap coverage Catastrophic coverage phase
phase phase

Catastrophic coverage phase
Gap coverage
Generic drugs:
phase
Initial coverage Generic drugs: $3.70 copay or 5% (whichever costs
Preferred Generic phase 25% more)
$0.00 copay Brand-name drugs:
Brand-name drugs:
$9.20 copay or 5% (whichever costs
25%
more)

Catastrophic coverage phase
Gap coverage
Generic drugs:
phase
Initial coverage Generic drugs: $3.70 copay or 5% (whichever costs
Generic phase 25% more)
$19.00 copay Brand-name drugs:
Brand-name drugs:
$9.20 copay or 5% (whichever costs
25%
more)

Catastrophic coverage phase
Gap coverage
phase Generic drugs:
Initial coverage Generic drugs: $3.70 copay or 5% (whichever costs
Preferred Brand phase 25% more)

$46.00 copay Brand-name drugs:
Brand-name drugs:
$9.20 copay or 5% (whichever costs
25%
more)

Catastrophic coverage phase
Gap coverage
phase Generic drugs:
Initial coverage Generic drugs: $3.70 copay or 5% (whichever costs
Non-Preferred more)
Drug phase 25%
48% Brand-name drugs:
Brand-name drugs:
$9.20 copay or 5% (whichever costs
25%
more)

Catastrophic coverage phase

Gap coverage
phase
Initial coverage Generic drugs:
phase Generic drugs:
Specialty Tier $3.70 copay or 5% (whichever costs
25%
25% more)
Brand-name drugs:
25% Brand-name drugs:
$9.20 copay or 5% (whichever costs
more)