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FloriclaBlue 10 V <br />In the pursuit of health <br />Indian River County BOCC #90000 <br />2018 BlueMedicare Group Rx (Employer PDP) <br />Premium <br />Included in PP02Rx1 <br />Annual Deductible <br />$0 <br />31 -day Supply <br />Retail <br />Tier 1 - Preferred Generics <br />$10 Copayment <br />Tier 2 - Generics <br />$10 Copayment <br />Tier 3 - Preferred Brand <br />$40 Copayment <br />Tier 4 - Non -Preferred Brand <br />$70 Copayment <br />Tier 5 - Specialty Drugs <br />25% Coinsurance <br />Mail Order 90 -day Supply with Mail Order <br />Tier 1 - Preferred Generics $0 Copayment <br />Tier 2 - Generics $0 Copayment <br />Tier 3 - Preferred Brand $80 Copayment <br />Tier 4 - Non -Preferred Brand $140 Copayment <br />Tier 5 - Specialty Drugs 25% Coinsurance (31 -day supply only) <br />Gap <br />31 -day Supply <br />Tier 1 - Preferred Generics $10 Copayment <br />Tier 2 - 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 />$3.35 Copayment for generic drugs <br />Catastrophic <br />$8.35 Copayment for 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 copayments do not accumulate towards the health Plan Year out-of-pocket <br />maximum. <br />Part D Creditable Coverage — The enrolling member may incur Part D late enrollment penalties as <br />defined and set by CMS in accordance with Part D guidelines if prior creditable coverage cannot be <br />proven. <br />Y0011 33942 0817 EGW P C: 09/2017 <br />