Page 77 - Cover Letter & Evaluation for Michael Novotny

6/9/2018 Your Medicare Health Plan Details
Eyeglasses (frames and $0 copay
lenses)
There may be limits on how much the plan will provide.
Eyeglass frames $0 copay

There may be limits on how much the plan will provide.
Eyeglass lenses $0 copay

There may be limits on how much the plan will provide.
Upgrades Not covered

Optional Supplemental Benefits

None Available

Drug Plan Information

Outpatient Prescription
Drugs
Monthly Premium $0.00
Deductible $0
Formulary Website View formulary website 
Initial Coverage Phase
Tier 1 Preferred Generic
1-Month: $1.00 copay
3-Month: $3.00 copay
All: Not Available

Tier 2 Generic
1-Month: $5.00 copay
3-Month: $15.00 copay
All: Not Available
Tier 3 Preferred Brand
1-Month: $30.00 copay
3-Month: $90.00 copay
All: Not Available

Tier 4 Non-Preferred Brand
1-Month: $75.00 copay
3-Month: $225.00 copay
All: Not Available

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

Tier 6 Select Care Drugs
1-Month: $3.00 copay
3-Month: $0.00 copay
All: Not Available

After you pay your deductible, if applicable, up to the initial coverage limit of $3,750
Coverage Gap Phase
Tier 1 Preferred Generic
1-Month: $1.00 copay
3-Month: $3.00 copay
All: Not Available

https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H3815&plnid=001&sgmntid=0#plan_benefits 4/5