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Providence Health Plan is a health plan with a Medicare contract. - page 19 / 32

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SUMMARY OF BENEFITS

If you have any questions about this plan’s benefits or costs, please contact Providence Health Plan.

Benefit Category

Original Medicare

Providence Medicare Extra + RX

29 - Prescription Drugs (continued)

Mail Order Tier 1: Generic Drugs

$6 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.

$18 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.

$9 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.

$27 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.

Tier 2: Brand Drugs

$45 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.

$135 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.

$45 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.

$135 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.

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