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■ You pay the same copays that you paid in the Initial Coverage Stage for all drugs. Once you leave <br />the Initial Coverage Stage, you move on to the Catastrophic Coverage Stage. <br />Catastrophic Coverage Stage <br />After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy <br />and through mail order) reach $7,400, you pay the greater of: <br />■ $4.15 copay for generic drugs in all tiers (including brand drugs treated as generic) and an $10.35 <br />copay for all other drugs in all tiers, or 5% of the cost. <br />Additional Drug Coverage <br />■ Please call us or see the plan's "Evidence of Coverage" on our website <br />(www.floridablue.com/medicare) for complete information about your costs for covered drugs. <br />If you request and the plan approves a formulary exception, you will pay Tier 4 (Non -Preferred <br />Drug) cost-sharing. <br />■ Your cost-sharing may be different if you use a Long -Term Care (LTC) pharmacy, a home infusion <br />pharmacy, or an out -of -network pharmacy, or if you purchase a long-term supply (up to 90 days) of <br />a drug. <br />Disclaimers <br />Florida Blue is a PPO and Rx (PDP) plan with a Medicare contract. Enrollment in Florida Blue depends <br />on contract renewal. <br />Out-of-network/non-contracted providers are under no obligation to treat Florida Blue members, <br />except in emergency situations. Please call our customer service number or see your Evidence of <br />Coverage for more information, including the cost-sharing that applies to out -of -network services. <br />If you have any questions, please contact our Member Services number at 1-800-926-6565. (TTY users <br />should call 1-800-955-8770.) Our hours are 8:00 a.m. to 8:00 p.m. local time, seven days a week, from <br />October 1 through March 31, except for Thanksgiving and Christmas. From April 1 through September <br />30, our hours are 8:00 a.m. to 8:00 p.m. local time, Monday through Friday, except for major holidays. <br />Health coverage is offered by Blue Cross and Blue Shield of Florida, Inc., dba Florida Blue, an <br />Independent Licensee of the Blue Cross and Blue Shield Association. <br />Plans may offer supplemental benefits in addition to Part C and Part D benefits. <br />© 2022 Blue Cross and Blue Shield of Florida, Inc., DBA Florida Blue. All rights reserved. <br />We comply with applicable Federal civil rights laws and do not discriminate on the basis of <br />race, color, national origin, age, disability or sex. Visit floridablue.com/ndnotice for <br />information on our free language assistance services. <br />14 340 <br />