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Part D Prescription Drug Benefits <br />Deductible Stage <br />This plan does not have a prescription drug deductible. <br />Initial Coverage Stage <br />You begin in this stage when you fill your first prescription of the year. <br />During this stage, the plan pays its share of the cost of your drugs, and you pay your share of the cost <br />(your copayment -or coinsurance amount). You stay in the Initial Coverage Stage until your total out-of-pocket <br />costs reach $2,000. You then move on to the Catastrophic Coverage Stage. You may get your drugs at network <br />retail pharmacies and mail order pharmacies. <br />Tier 1 - Preferred Generic <br />Tier 2 - Generic <br />Tier 3 - Preferred Brand <br />i ier 4 - ivon-Nreterrea vrug <br />tailsl, Standard Retail Standard Retail Mail Order"(90 to ' <br />(31 -day supply) (90 to 100 -day 100 -day supply) <br />�...�? supply) <br />$3 copay $9 copay $0 copay <br />$8 copay $24 copay $8 copay <br />$35 copay $105 copay $70 copay <br />$65 copay $195 copay $195 copay <br />Tier 5 - Specialty Tier 33% of the cost N/A NIA <br />i <br />You won't pay more than $35 for a one-month supply of each covered insulin product regardless of the <br />cost-sharing tier. <br />Catastrophic Coverage Stage <br />You enter the Catastrophic Coverage Stage when your out-of-pocket costs have reached the $2,000 limit <br />for the calendar year. During the Catastrophic Coverage Stage, you pay nothing for your covered Part D <br />drugs. You will stay in this payment stage until the end of the calendar year. <br />Additional Drug Coverage <br />Please call us or see the plan's "Evidence of Coverage" on our website <br />(www,floridablue.com/medicare/forms) for complete information about your costs for covered <br />drugs. If you request and the plan approves a formulary exception, you will pay Tier 4 (Non -Preferred <br />Drug) cost-sharing. <br />15 <br />