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In the pursuit of health <br /> Indian River County BOCC #90000 <br /> 2015 BlueMedicare Group Rx*(Employer PDP) <br /> ,,,Benefits BlueMedicare Group R' <br /> Option <br /> Premium Included with PPO1 Rx1 <br /> Annual Deductible $0 — <br /> Retail 31-day Supply <br /> Tier 1 - Preferred Generics $10 Copayment <br /> Tier 2 - Non-Preferred Generics $10 Copayment <br /> Tier 3- Preferred Brand $40 Copayment — <br /> Tier 4- Non-Preferred Brand $70 Copayment <br /> Tier 5- Specialty Drugs 25% Coinsurance <br /> Mail Order — — —`— 90-day Supply with PRIME Mail Order <br /> Tier 1 - Preferred Generics $0 Copayment <br /> Tier 2 _Non_Preferred Generics _-- $0 Copayment <br /> Tier 3 - Preferred Brand .$80 Copayment <br /> Tier 4_Non-Preferred Brand I $140 Copayment <br /> Tier 5 - Specialty Drugs 25% Coinsurance <br /> Gap ------ — - ---- 31-day Supply <br /> Tier 1 - Preferred Generics $10 Copayment <br /> Tier 2 - Non-Preferred Generics $10 Copayment — <br /> Tier 3 - Preferred Brand $40 Copayment <br /> Tier 4=Non-Preferred Brand_ $70 Copayment <br /> Tier 5- Specialty Drugs 25% Coinsurance —j <br /> Greater of$2.65 Copayment or 5%o Coinsurance for I <br /> Catastrophic ; generic drugs ` <br /> Greater of$6.60 Copayment or 5% Coinsurance for <br /> brand drugs <br /> Florida Blue is an Rx (PDP) Plan with a Medicare contract. Enrollment in Florida Blue depends on <br /> contract renewal. <br /> Prescription drug copays do not accumulate towards the health plan annual out-of-pocket maximum ' <br /> Part D Creditable Coverage—The enrolling member may incur late enrollment penalties as defined and <br /> set by CMS in accordance with Part D guidelines if prior creditable coverage cannot be proven <br /> Y0011_31876 0414R1 EGWP C: 06/2014 <br /> 109 <br />