Page 36 - Cover letter and evaluation for Michele Buros

Your Medicare Health Plan Details https://www.medicare.gov/find-a-plan/results/planresults/plan-details.as...

Optional Supplemental Benefits

None Available

Drug Plan Information

Outpatient Prescription Drugs
Monthly Premium $12.90
Deductible $0
Formulary Website View formulary website
Initial Coverage Phase
Tier 1 Preferred Generic
1-Month: $0.00 copay
3-Month: $0.00 copay
All: Not Available

Tier 2 Generic
1-Month: $15.00 copay
3-Month: $45.00 copay
All: Not Available

Tier 3 Preferred Brand
1-Month: $42.00 copay
3-Month: $126.00 copay
All: Not Available
Tier 4 Non-Preferred Drug
1-Month: $90.00 copay
3-Month: $270.00 copay
All: Not Available

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