Page 88 - Cover Letter & Evaluation for Michael Novotny

6/9/2018 Your Medicare Health Plan Details
Package #2 Comprehensive dental services, Preventive dental services
Monthly Premium $2.50
Deductible N/A

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: $4.00 copay
3-Month: $12.00 copay
All: Not Available

Tier 2 Generic
1-Month: $10.00 copay
3-Month: $30.00 copay
All: Not Available
Tier 3 Preferred Brand
1-Month: $47.00 copay
3-Month: $141.00 copay
All: Not Available

Tier 4 Non-Preferred Drug
1-Month: $100.00 copay
3-Month: $300.00 copay
All: Not Available

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

After you pay your deductible, if applicable, up to the initial coverage limit of $3,750
Coverage Gap Phase
Generic drugs Generic drugs
44%
Brand-name drugs Brand-name drugs
35%
After the total drug costs paid by you and the plan reach $3,750, up to the out-of-pocket threshold of $5,000
Catastrophic Coverage
Phase
Generic drugs Generic drugs
Greater of 5% or $3.35 copay
Brand-name drugs Brand-name drugs
Greater of 5% or $8.35 copay
When your annual out-of-pocket costs exceed $5,000

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