Prescription Drug Summary

The Medicare Advantage Part D Program is a wide-ranging benefit that provides coverage for prescription drugs when prescribed by a licensed, practicing physician. The Part D drug program is based on an incentive formulary that includes the majority of generic drugs and a defined list of brand drugs that have been evaluated for their medical effectiveness, positive results, and value. Generic drugs are just as effective as brand drugs and result in the lowest cost sharing for you. Ask your physician whether generic drugs are right for you. Also, you may be able to maximize your benefit by using our preferred pharmacy network to get the lower copay. While you can use other pharmacies in the network, you will likely pay more for drugs at these locations. Please refer to your EOC for additional information about your pharmacy benefits. Benefit Coverage Prescription Drug deductible $0 Initial Coverage After you pay your annual deductible, you pay the following copays until you reach the total yearly drug costs (paid by member and plan) 30-day supply at a network Retail pharmacy

Tier 1 Generic Drugs $10 copay (Standard Pharmacy) $5 copay (Preferred Pharmacy) Tier 2 Preferred Brand $15 copay (Standard Pharmacy) $15 copay (Preferred Pharmacy) Tier 3 Non-Preferred Drugs $30 copay (Standard Pharmacy) $30 copay (Preferred Pharmacy) Up to 90-day supply at a network Retail pharmacy

Tier 1 Generic Drugs $30 copay (Standard Pharmacy) $15 copay (Preferred Pharmacy) Tier 2 Preferred Brand $45 copay (Standard Pharmacy) $45 copay (Preferred Pharmacy) Tier 3 Non-Preferred Drugs $90 copay (Standard Pharmacy) $90 copay (Preferred Pharmacy) Up to 90-day supply Through network Mail-Order pharmacy

Tier 1 Generic Drugs $5 copay (Preferred Pharmacy) Tier 2 Preferred Brand $15 copay (Preferred Pharmacy) Tier 3 Non-Preferred Drugs $30 copay (Preferred Pharmacy)

www.ibx.com

12/14 - PA - IND #B4T/PC65 - EG - Unlimited Gap Coverage(Wrap) Benefit Coverage Non-Participating Retail Pharmacy Out of Network Reimbursement is cost of the drug minus the applicable copayment Coinsurance & Maximums Annual Maximum No Initial Coverage Limit $0 Annual OOP Cost $4,950 Catastrophic Coverage Once your annual out-of-pocket drugs cost has been reached, you pay the greater of: Generics (including brand drugs $3.30 or 5% treated as generic) All other drugs $8.25 or 5%