Page 76 - Cover letter and evaluation for Michele Buros

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Outpatient Prescription Drugs
Monthly Premium $25.10
Deductible $0
Formulary Website View formulary website
Initial Coverage Phase
Tier 1 Preferred Generic
1-Month: $2.00 copay
3-Month: $6.00 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: $42.00 copay
3-Month: $126.00 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: Not Available
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: $2.00 copay
3-Month: $6.00 copay
All: Not Available

Tier 2 Generic
1-Month: $5.00 copay
3-Month: $15.00 copay
All: Not Available

All drugs may not be offered with additional gap coverage, for all other drugs, you pay 44% for generic drugs and 35% for brand-
name drugs.
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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