Tier 1: Preferred Generic $1 $3 $0 $0 
Tier 2: Generic $2 $6 $1 $3 
Tier 3: Preferred Brand 23% 23% 19% 19% 
Tier 4: Non-Preferred 
Drug 45% 45% 41% 41% 
Tier 5: Specialty Tier 25% N/A 25% N/A 
If you receive Extra Help for your drugs, you'll pay the following: 
Deductible You may pay  $0 or  $104 depending on your level of "Extra Help" .If your deductible is  $104 , 
you pay the full cost of your drugs until you reach  $104 .Then, you only pay your cost-share. 
Pharmacy cost-sharing 
For generic drugs