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2012 Secure Blue PPO Out-of-Network Prescription Drug Cost Sharing

Your initial share of the cost when you get a 30-day supply (or less) of a
covered Part D prescription drug from an out-of-network pharmacy:

Cost-Sharing
Tier 1

Generics

$10 Copayment

Difference between in-network and out-of-network costs may apply.

Cost-Sharing
Tier 2

Preferred Brand

$45 Copayment

Difference between in-network and out-of-network costs may apply.

Cost-Sharing
Tier 3

Non-Preferred Brand

$95 Copayment

Difference between in-network and out-of-network costs may apply.

Cost-Sharing
Tier 4

Specialty Drugs

33% Coinsurance

Difference between in-network and out-of-network costs may apply.

(Coverage is limited to certain situations; see Evidence of Coverage for details.)

Y0010_MK 12155 CMS Approval 11/9/2011