Page 73 - Cover Letter and Evaluation for Amy Prack

Drug Plan Information
Outpatient Prescription
Drugs
Monthly Premium $22.20
Deductible $170
Formulary Website View formulary website 
Initial Coverage Phase
Tier 1 Preferred Generic
1-Month: $2.00 copay
3-Month: $4.00 copay
All: Not Available
Tier 2 Generic
1-Month: $8.00 copay
3-Month: $16.00 copay
All: Not Available

Tier 3 Preferred Brand
1-Month: $45.00 copay
3-Month: $135.00 copay
All: Not Available

Tier 4 Non-Preferred Drug
1-Month: $95.00 copay
3-Month: $285.00 copay
All: Not Available

Tier 5 Specialty Tier
1-Month: 29%
3-Month: 29%
All: Not Available

Gap Coverage Phase
Tier 1 Preferred Generic
1-Month: $2.00 copay
3-Month: $4.00 copay
All: Not Available
Tier 2 Generic
1-Month: $8.00 copay
3-Month: $16.00 copay
All: Not Available

• For all other drugs, you pay 37% for generic drugs and 25% for brand-name drugs.
Catastrophic Coverage
Phase
Generic drugs Generic drugs
$3.40 copay or 5% (whichever costs more)
Brand-name drugs Brand-name drugs
$8.50 copay or 5% (whichever costs more)

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