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. 
Catastrophic Coverage 
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and 
through mail order) reach  $7,400 ,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 
Additional Benefits