PPO II - EmblemHealth

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Your share of the cost when you get a one-month supply (or less)
of a covered Part D prescription drug from:
Cost-Sharing
Tier 1
(Preferred Generic
Drugs)
Cost-Sharing
Tier 2
(Preferred Brand
Drugs)
Cost-Sharing
Tier 3
(Non-Preferred
Brand Drugs)
Cost-Sharing
Tier 4
(Specialty Drugs)
$5 copayment
2013 Evidence of Coverage for PPO II
Chapter 6: What you pay for your Part D prescription drugs
Network
pharmacy
(up to a 30-day
supply))
$35 copayment
$95 copayment
The plan’s mailorder
service
(up to a 30-day
supply)
$5 copayment
$35 copayment
$95 copayment
Network
long-term care
pharmacy
(up to a 31-day
supply)
$5 copayment
$35 copayment
$95 copayment
Out-of-network
pharmacy
(coverage is
limited to certain
situations;
see Chapter 5
for details)
(up to a 30-day
supply)
$5 copayment
$35 copayment
$95 copayment
25% coinsurance 25% coinsurance 25% coinsurance 25% coinsurance
Section 5.3 A table that shows your costs for a long-term
(90-day) supply of a drug
For some drugs, you can get a long-term supply (also called an “extended supply”) when you fi ll your
prescription. A long-term supply is up to a 90-day supply. (For details on where and how to get a longterm
supply of a drug, see Chapter 5.)
Th e table below shows what you pay when you get a long-term (up to a 90-day) supply of a drug.
• Please note: If your covered drug costs less than the copayment amount listed in the chart, you
will pay that lower price for the drug. You pay either the full price of the drug or the copayment
amount, whichever is lower.