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Providence Health Plan is a health plan with a Medicare contract. - page 21 / 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

29 - Prescription Drugs (continued)

Original Medicare

Providence Medicare Extra + RX Out-of-Network Initial Coverage

You will be reimbursed up to the full cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2,840:

Tier 1: Generic Drugs

$9 copay for a one-month (30-day) supply of drugs in this tier.

Tier 2: Brand Drugs

$45 copay for a one-month (30-day) supply of drugs in this tier.

Tier 3: Specialty Tier Drugs

33% coinsurance for a one- month (30-day) supply of drugs in this tier.

You will not be reimbursed for the difference between the Out-of- Network Pharmacy charge and the plan's In-Network allowable amount.

Out-of-Network Coverage Gap

You will be reimbursed up to 7% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4,550.

You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4,550.

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