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� <br />| <br /> B& 0 V <br /> |nthe ��U��Wit �f h��8l+�� <br /> . - <br /> Indian River CQUnt» BnordnfCOUOh/ Commissioners <br /> 20141B/WeMed'care Group Rx* <br /> end <br /> Premium Included in PP01 Plan Offer <br /> tDedfuctible $0 <br /> Retail 31-day Supply <br /> Tier 1 - Preferred Generics $10 <br /> Tier 2 - Non-Preferred Generics $10 <br /> Tier 3 - Preferred Brand $40 <br /> Tier 4 - Non-Preferred Brand $70 <br /> Tier 5 - Specialty Drugs 25% <br /> Mail Order 90-day Supply with PRIME Mail Order <br /> Tier 1 - Preferred Generics $0 <br /> Tier 2 - Non-Preferred Generics $0 <br /> Tier 3- Preferred Brand $80 <br /> Tier 4 - Non-Preferred Brand $140 <br /> Tier 5 - Specialty Drugs 25% <br /> Formulary Type 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 31-day Supply <br /> Tier 1 - Preferred Generics $10 <br /> Tier 2 - Non-Preferred Generics $10 <br /> Tier 3 - Preferred Brand $40 <br /> Tier 4 - Non-Preferred Brand $70 <br /> Tier 5 - Specialty Drugs 25% <br /> Catastrophic Greater of$2.55 or 5%/Greater of$6.35 or 5% <br /> * Florida Blue iaanRx (PDP) Plan with aMedicare 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_319640812EGVVPC: 08/2013 <br />