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In the pursuit of health - Indian River County BOCC #90000 2015 BlueMedicare Group Rx* (Employer PDP) • Benefits, s Y Premium BlueMedicare Group Rx*Option 1 Included with PPO1Rx1 Annual Deductible $0 Retail 31 -day Supply Tier 1 - Preferred Generics $10 Copayment Tier 2 - Non -Preferred Generics $10 Copayment Tier 3 - Preferred Brand $40 Copayment Tier 4 - Non -Preferred Brand $70 Copayment Tier 5 - Specialty Drugs 25% Coinsurance Mail Order 90 -day Supply with PRIME Mail Order Tier 1 - Preferred Generics $0 Copayment Tier 2 - Non -Preferred Generics $0 Copayment Tier 3 - Preferred Brand $80 Copayment Tier 4 - Non -Preferred Brand $140 Copayment Tier 5 - Specialty Drugs 25% Coinsurance Gap 31 -day .Supply Tier 1 - Preferred Generics $10 Copayment Tier 2 - Non -Preferred Generics $10 Copayment Tier 3 - Preferred Brand $40 Copayment Tier 4 - Non -Preferred Brand $70 Copayment Tier 5 - Specialty Drugs 25% Coinsurance Catastrophic Greater of $2.65 Copayment or 5% Coinsurance for generic drugs Greater of $6 60 Copayment or 5% Coinsurance for brand drugs * Florida Blue is an Rx (PDP) Plan with a Medicare contract Enrollment in Florida Blue depends on contract renewal Prescription drug copays do not accumulate towards the health plan annual out-of-pocket maximum Part D Creditable Coverage — The enrolling member may incur late enrollment penalties as defined and set by CMS in accordance with Part D guidelines if prior creditable coverage cannot be proven Y0011_31876 0414R1 EGWP C 06/2014