Tier 2(Generic) - All Drugs 
Tier 3(Preferred Brand) - Select Insulin Drugs 
For more information on cost sharing in the coverage gap, please call us or access your Evidence of 
Coverage online. 14 Summary of Benefits H1036236000SB23 H1036236000 
Catastrophic Coverage 
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and 
through mail order) reach  $7,4 00 you pay the greater of: 
•5% of the cost, or