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Flor. Mae �4a, <br />In the pursuit of health' <br />Indian River County Board of County Commissioners <br />2014 BlueMedicare Group Rx* <br />[.�'c4fi } `` ` <br />�!1 eflTs �% � �w y � css6' L�{«C�x <br />+ (�y /} {�.�:° p xR ,,y���--' p - �r"'v Yk 9' j <br />.131ueliMpdae l e Gr up T,^_�i„ Opt/o ST'F�,� ', "7 �} "`9✓. <br />Premium <br />Included in PPO1 Plan Offer <br />Deductible <br />$0 <br />Retail <br />31 -day Supply <br />$10 <br />Tier 1 - Preferred Generics <br />Tier 2 - Non -Preferred Generics <br />$10 <br />Tier 3 - Preferred Brand <br />$40 <br />Tier 4 - Non -Preferred Brand <br />$70 <br />Tier 5 - Specialty Drugs <br />25% <br />Mail Order <br />90 -day Supply with PRIME Mail Order <br />Tier 1 - Preferred Generics <br />$0 <br />Tier 2 - Non -Preferred Generics <br />$0 <br />Tier 3 - Preferred Brand <br />$80 <br />Tier 4 - Non -Preferred Brand <br />$140 <br />Tier 5 - Specialty Drugs <br />25% <br />Formulary Type <br />Added coverage for selected CMS excluded drugs. Generic <br />& multi -source brand prescription drugs will be covered for <br />the following categories: <br />• Cough <br />• Cold <br />Gap <br />31 -day Supply <br />Tier 1 - Preferred Generics <br />$10 <br />Tier 2 - Non -Preferred Generics <br />$10 <br />Tier 3 - Preferred Brand <br />$40 <br />Tier 4 - Non -Preferred Brand <br />$70 <br />Tier 5 - Specialty Drugs <br />25% <br />Catastrophic <br />Greater of $2.55 or 5% / Greater of $6.35 or 5% <br />• Florida Blue is an Rx (PDP) Plan with a Medicare contract. <br />• Prescription drug copays do not accumulate towards the health plan calendar year out-of-pocket <br />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_31964 0612 EGWP C: 06/2013 <br />