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Florida flue C;) <br />In the pursuit of health <br />Indian River County Board of County Commissioners <br />2014 BlueMedicare Group Rx* <br />Premium Included in PPO1 Plan Offer <br />Deductible ' $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 j 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 />Gaj 31 -day Suppler <br />Tier 1 - Preferred Generics _4 $10 <br />Tier 2 - Non -Preferred Generics $10 <br />Tier 3 - Preferred Brand $40 <br />Tier 4 - Non -Preferred Brand 1 $70 <br />Tier 5 - Specialty Drugs 25% <br />Catastrophic 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 />106 <br />