Page 68 - Cover Letter & Evaluation for Patricia Letizia

10/11/2018 Your Medicare Health Plan Details
Eyeglasses (frames and In-Network: $0 copay
lenses) Out-of-Network: $0 copay

There may be limits on how much the plan will provide.
Eyeglass frames In-Network: $0 copay
Out-of-Network: $0 copay

There may be limits on how much the plan will provide.
Eyeglass lenses In-Network: $0 copay
Out-of-Network: $0 copay

There may be limits on how much the plan will provide.
Upgrades In-Network: $0 copay
Out-of-Network: $0 copay

There may be limits on how much the plan will provide.
Optional Supplemental Benefits

None Available

Drug Plan Information
Outpatient Prescription
Drugs
Monthly Premium $17.00
Deductible $95
Formulary Website View formulary website 
Initial Coverage Phase
Tier 1 Preferred Generic
1-Month: $0.00 copay
3-Month: $0.00 copay
All: Not Available

Tier 2 Generic
1-Month: $0.00 copay
3-Month: $0.00 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: 31%
3-Month: Not Available
All: Not Available

Gap Coverage Phase
Tier 1 Preferred Generic
1-Month: $0.00 copay
3-Month: $0.00 copay
All: Not Available

https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H5521&plnid=150&sgmntid=0#plan_benefits 5/6