For more information on cost sharing in the coverage gap, please call us or access your Evidence of 
Coverage online. 14 Summary of Benefits H1036234000SB23 H1036234000 
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 
•$4.15 copay for generic (including brand drugs treated as generic) and a  $10.35 copay for all other 
drugs