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2013 True Blue HMO Option I 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

$8 Copayment

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

Cost-Sharing
Tier 2

Preferred Brand

$33 Copayment

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

Cost-Sharing
Tier 3

Non-Preferred Brand

$72 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.)

2013 True Blue HMO Option II 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

$8 Copayment

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

Cost-Sharing
Tier 2

Preferred Brand

$33 Copayment

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

Cost-Sharing
Tier 3

Non-Preferred Brand

$72 Copayment

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

Cost-Sharing
Tier 4

Specialty Drugs

25% Coinsurance

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

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

2013 True Blue Freedom HMO 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

28% 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 13121 Approved 12-31-2012
Last updated 11-14-2012