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Providence Health Plan is a health plan with a Medicare contract. - page 20 / 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)

Tier 3: Specialty Tier Drugs 33% coinsurance for a one- month (30-day) supply of drugs in this tier from a preferred mail order pharmacy. 33% coinsurance for a one- month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.

Coverage Gap After your total yearly drug costs reach $2840, you receive a discount on brand name drugs and pay 93% of the plan's costs for all generic drugs until your yearly out- of-pocket drug costs reach $4,550.

Catastrophic Coverage After your yearly out-of-pocket drug costs reach $ 4,550, you pay the greater of:

A $ 2.50 copay for generic (including brand drugs treated as generic) and a $ 6.30 copay for all other drugs, or

5% coinsurance.

Out-of-Network Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost- sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Providence Medicare Extra + RX.

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