Page 75 - APPENDICES for Neill McLauchlin

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I Initial coverage G a p c o v e r a g e
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Gap coverage
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Tiers Catastrophic coverage phase

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phase phase
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Preferred Generic $0.00 copay
Generic drugs:
Generic $7.00 copay Generic drugs: $3.70 copay or 5% (whichever costs
25%
Preferred Brand $43.00 copay more)
Brand-name
Non-Preferred drugs: Brand-name drugs:
49% $9.20 copay or 5% (whichever costs
Drug 25%
more)
Specialty Tier 25%
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
WALMART PHARMACY 10-1666 Standard 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.

WALMART PHARMACY 10-1666 - Drug costs during coverage
phases

Standard in-network pharmacy