Page 118 - Cover Letter and Evaluation for John

10/9/2018 Your Medicare Health Plan Details
Package #2 Comprehensive dental, Comprehensive dental services, Hearing aids, Preventive dental, Preventive
dental services
Monthly Premium $26.00
Deductible $50.00

Drug Plan Information

Outpatient Prescription
Drugs
Monthly Premium $39.60
Deductible $0
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: 33%
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
Tier 2 Generic
1-Month: $0.00 copay
3-Month: $0.00 copay
All: Not Available

For all other drugs, you pay 37% for generic drugs and 25% for brand-name drugs.

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)

Return to previous page
https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H5521&plnid=126&sgmntid=0#plan_benefits 5/5