Page 79 - Cover Letter and Evaluation for Debbie Workman

12/13/2017 Your Medicare Health Plan Details
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: $8.00 copay
3-Month: $24.00 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

After you pay your deductible, if applicable, up to the initial coverage limit of $3,750
Coverage Gap Phase
Generic drugs Generic drugs
44%
Brand-name drugs Brand-name drugs
35%
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

Return to previous page

https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H1286&plnid=002&sgmntid=0 4/4