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Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue
ValueRx (HMO) PlusRx (HMO) FlexRx (HMO-POS)

Coverage Gap Most Medicare drug Most Medicare drug Most Medicare drug
plans have a coverage plans have a coverage plans have a coverage
gap (also called the gap (also called the gap (also called the
“donut hole”). This “donut hole”). This “donut hole”). This
means that there’s a means that there’s a means that there’s a
temporary change in temporary change in temporary change in
what you will pay for what you will pay for what you will pay for
your drugs. The coverage your drugs. The coverage your drugs. The coverage
gap begins after the gap begins after the gap begins after the
total yearly drug cost total yearly drug cost total yearly drug cost
(including what our (including what our (including what our
plan has paid and what plan has paid and what plan has paid and what
you have paid) reaches you have paid) reaches you have paid) reaches
$3,700. $3,700. $3,700.

After you enter the After you enter the After you enter the
coverage gap, you pay coverage gap, you pay coverage gap, you pay
40% of the plan’s cost 40% of the plan’s cost 40% of the plan’s cost
for covered brand name for covered brand name for covered brand name
drugs and 51% of the drugs and 51% of the drugs and 51% of the
plan’s cost for covered plan’s cost for covered plan’s cost for covered
generic drugs until generic drugs until generic drugs until
your costs total $4,950, your costs total $4,950, your costs total $4,950,
which is the end of which is the end of which is the end of
the coverage gap. Not the coverage gap. Not the coverage gap. Not
everyone will enter the everyone will enter the everyone will enter the
coverage gap. coverage gap. coverage gap.
Catastrophic After your yearly After your yearly After your yearly
Coverage out-of-pocket drug out-of-pocket drug out-of-pocket drug
costs (including drugs costs (including drugs costs (including drugs
purchased through your purchased through your purchased through your
retail pharmacy and retail pharmacy and retail pharmacy and
through mail order) through mail order) through mail order)
reach $4,950, you pay reach $4,950, you pay reach $4,950, you pay
the greater of: the greater of: the greater of:
• 5% of the cost, or • 5% of the cost, or • 5% of the cost, or
• $3.30 copay for generic • $3.30 copay for generic • $3.30 copay for generic
(including brand drugs (including brand drugs (including brand drugs
treated as generic) and treated as generic) and treated as generic) and
a $8.25 copayment for a $8.25 copayment for a $8.25 copayment for
all other drugs. all other drugs. all other drugs.

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