Page 82 - Cover Letter & Evaluation for Patricia Letizia

10/11/2018 Your Medicare Health Plan Details
Eyeglass lenses Not covered

Upgrades Not covered

Optional Supplemental Benefits

Package #1 Comprehensive dental, Comprehensive dental services, Preventive dental, Preventive dental services
Monthly Premium $35.00
Deductible $100.00

Drug Plan Information

Outpatient Prescription
Drugs
Monthly Premium $0.00
Deductible $275
Formulary Website View formulary website 
Initial Coverage Phase
Tier 1 Preferred Generic
1-Month: $2.00 copay
3-Month: $5.00 copay
All: Not Available

Tier 2 Generic
1-Month: $8.00 copay
3-Month: $20.00 copay
All: Not Available

Tier 3 Preferred Brand
1-Month: $42.00 copay
3-Month: $105.00 copay
All: Not Available
Tier 4 Non-Preferred Brand
1-Month: $84.00 copay
3-Month: $210.00 copay
All: Not Available

Tier 5 Specialty Tier
1-Month: 27%
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
Tier 1 Preferred Generic
$3.40 copay or 5% (whichever costs more)
Tier 2 Generic
$3.40 copay or 5% (whichever costs more)
Tier 3 Preferred Brand
$8.50 copay or 5% (whichever costs more)
Tier 4 Non-Preferred Brand
$8.50 copay or 5% (whichever costs more)
Tier 5 Specialty Tier
$8.50 copay or 5% (whichever costs more)

https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H5215&plnid=009&sgmntid=0#plan_benefits 5/6