Tier 2: Generic  $20 $60 $20 $60 
Tier 3: Preferred 
Brand  $35 $105 $35 $105 
Cost sharing may change depending on the pharmacy you choose, when you enter another phase of the  
Part Dbenefit and if you qualify for "Extra Help." To find out if you qualify for "Extra Help," please contact  
the Social Security Office at 1-800-772-1213 Monday —Friday, 7a.m. —7p.m. TTY users should call  
1-800-325-0778. For more information on the additional pharmacy-specific cost-sharing and the phases