Page 63 - Cover letter and evaluation for Michele Buros

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

Routine eye exam In-Network: $0
Out-of-Network: $0 copay

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

Contact lenses Not covered

Eyeglasses (frames and Not covered
lenses)
Eyeglass frames Not covered

Eyeglass lenses Not covered

Upgrades Not covered

Optional Supplemental Benefits

None Available

Drug Plan Information

Outpatient Prescription Drugs
Monthly Premium $27.40
Deductible $325
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: $13.00 copay
3-Month: $39.00 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: 26%
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

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