Page 88 - Cover Letter and Evaluation for Amy Prack

Eyeglass frames Not covered
Eyeglass lenses Not covered

Upgrades Not covered

Optional Supplemental Benefits

Package #1 Comprehensive dental, Comprehensive dental services, Preventive dental, Preventive dental services
Monthly Premium $19.90
Deductible N/A

Package #2 Eye exams, Eyewear
Monthly Premium $15.30
Deductible N/A
Package #3 Comprehensive dental, Comprehensive dental services, Preventive dental, Preventive dental services
Monthly Premium $24.20
Deductible N/A

Drug Plan Information
Outpatient Prescription
Drugs
Monthly Premium $0.00
Deductible $250
Formulary Website View formulary website 
Initial Coverage Phase
Tier 1 Preferred Generic
1-Month: $7.00 copay
3-Month: $21.00 copay
All: Not Available

Tier 2 Generic
1-Month: $17.00 copay
3-Month: $51.00 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: 28%
3-Month: Not Available
All: Not Available

Gap Coverage Phase
Generic drugs Generic drugs
37%
Brand-name drugs Brand-name drugs
25%
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)