Page 48 - Cover Letter & Evaluation for Patricia Letizia

10/12/2018 Your Medicare Health Plan Details
Package #1 Eye exams, Eyewear
Monthly Premium $15.30
Deductible N/A

Package #2 Comprehensive dental, Comprehensive dental services, Preventive dental, Preventive dental services
Monthly Premium $19.60
Deductible N/A

Drug Plan Information

Outpatient Prescription
Drugs
Monthly Premium $11.40
Deductible $250
Formulary Website View formulary website 
Initial Coverage Phase
Tier 1 Preferred Generic
1-Month: $6.00 copay
3-Month: $18.00 copay
All: Not Available

Tier 2 Generic
1-Month: $15.00 copay
3-Month: $45.00 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)

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