Page 55 - APPENDICES for Stephen Spero

Preferred retail pharmacy drug cost for 1-month

Initial coverage Gap coverage
Tiers Catastrophic coverage phase
phase phase 1

Preferred
$0.00 copay
Generic

Generic $7.00 copay Generic drugs:

$3.60 copay or 5% (whichever costs
Preferred Brand $42.00 copay
more)

Non-Preferred
$95.00 copay Brand-name drugs:
Drug
$8.95 copay or 5% (whichever costs

Specialty Tier 33% more)

Select Care
$0.00 copay $0.00 copay
Drugs

1 For all other drugs, you pay 25% for generic drugs and 25% for brand-name drugs.

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.

RITE AID PHARMACY 05646 - Drug costs during coverage

phases

Standard in-network pharmacy

Cost in
Retail Cost after Cost after
Selected drugs coverage
cost deductible coverage gap
gap