2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 6: What you pay for your Part D prescription drugs 165 most charities count toward your out-of-pocket costs. Keep a record of these payments and send them to us so we can track your costs. · Check the written report we send you. When you receive a Part D EOB look it over to be sure the information is complete and correct. If you think something is missing or you have any questions, please call us at Customer Service. You can also view your EOB on our website at retiree.uhc.com/wapebb. Be sure to keep these reports. Section 4 During the Deductible Stage, you pay the full cost of your Tier 2, Tier 3 and Tier 4 drugs The Deductible Stage is the first payment stage for your drug coverage. You will pay a yearly deductible of $100 on Tier 2, Tier 3 and Tier 4 drugs. You must pay the full cost of your Tier 2, Tier 3 and Tier 4 drugs until you reach the plan’s deductible amount. The deductible doesn’t apply to covered insulin products and most adult Part D vaccines. The “full cost” is usually lower than the normal full price of the drug, since our plan has negotiated lower costs for most drugs at network pharmacies. Once you have paid $100 for your Tier 2, Tier 3 and Tier 4 drugs, you leave the Deductible Stage and move on to the Initial Coverage Stage. Your plan has a deductible of $100 in Tier 2, Tier 3 and Tier 4. However, your deductible will be different if you receive Medicare’s “Extra Help” with your prescription drug costs. Depending on the level of Extra Help you receive, your deductible may be as low as $0 but not more than $100. You will get a Low Income Subsidy Rider or LIS Rider in a separate mailing. It explains Extra Help and tells you the amount of your deductible. Section 5 During the Initial Coverage Stage, the plan pays its share of your drug costs and you pay your share Section 5.1 What you pay for a drug depends on the drug and where you fill your prescription During the Initial Coverage Stage, the plan pays its share of the cost of your covered prescription drugs, and you pay your share (your copayment or coinsurance amount). Your share of the cost will vary depending on the drug and where you fill your prescription. The plan has 4 cost-sharing tiers Every drug on the plan’s Drug List is in one of 4 cost-sharing tiers. In general, the higher the cost- sharing tier number, the higher your cost for the drug: Tier 1 – Preferred Generic - All covered generic drugs. In addition, Part D eligible generic drug compound medications are covered in Tier 1. This is the lowest cost-sharing tier. Tier 2 – Preferred Brand - Many common brand name drugs, called preferred brands. Tier 3 – Non-preferred Drug - Non-preferred brand name drugs. In addition, Part D eligible compound medications are covered in Tier 3.