Page 101 - APPENDICES for Fred Falten

a
i

l
t
I
Initial coverage G a p c o v e r a g e
i
n
g
a
Gap coverage
e
r
o
c
e
v
c

c
T i e r s Catastrophic coverage phase
s
a
Tiers
i
r
a
t
o
h
C
p
o
h
p
t
e
s
a

r
a
v
e
g
e
phase
p h a s e p h a s e 1 1
phase
Preferred
$0.00 copay $0.00 copay
Generic
Generic drugs:
Generic $2.00 copay $2.00 copay $3.70 copay or 5% (whichever costs
more)
Preferred Brand 20%
Brand-name drugs:
Non-Preferred $9.20 copay or 5% (whichever costs
38%
Drug more)
Specialty Tier 26%
1 For all other drugs, you pay 25% for generic drugs and 25% for brand-name drugs.
Pharmacies Change Pharmacies
See the cost level to ll your drugs at the pharmacies you chose. You can also change pharmacies to see
the cost level of other pharmacies in your area to nd the lowest cost pharmacy.
More about pharmacy cost levels
CVS PHARMACY #00846 Preferred in-network pharmacy
Mail Order Pharmacy Costs vary based on the speci c mail-order pharmacy

ESTIMATED DRUG COSTS DURING COVERAGE PHASES

The drug prices shown may vary based on the plan and pharmacy you've selected. Contact the plan if
you have speci c questions about drug costs.

Learn more about coverage phases.

CVS PHARMACY #00846 - Drug costs during coverage phases