|
Deductible
|
$320.00 (Brand Only)
|
$320.00 (Brand Only)
|
$0
|
|
Monthly Premium Rates
|
$62.00
|
$90.00
|
$298.00
|
|
|
|
INITIAL PERIOD - DRUG COSTS UP TO $2,930
|
|
Generic Drugs
|
$5.00
|
$5.00
|
$5.00
|
|
Preferred Brand Drugs
|
$40.00
|
$40.00
|
$40.00
|
|
Brand Drugs
|
$70.00
|
$70.00
|
$70.00
|
|
Specialty Drugs
|
$100.00
|
$100.00
|
$100.00
|
|
|
Mail Order
|
Pharmacy
|
Mail Order
|
Pharmacy
|
Mail Order
|
Pharmacy
|
|
Generic Drugs
|
$10.00
|
$12.50
|
$10.00
|
$12.50
|
$10.00
|
$12.50
|
|
Preferred Brand Drugs
|
$80.00
|
$82.50
|
$80.00
|
$82.50
|
$80.00
|
$82.50
|
|
Brand Drugs
|
$140.00
|
$145.00
|
$140.00
|
$145.00
|
$140.00
|
$145.00
|
|
Specialty Drugs
|
$200.00
|
$205.00
|
$200.00
|
$205.00
|
$200.00
|
$205.00
|
|
|
|
COVERAGE GAP
|
Amount you pay between the Initial Coverage Period and until you reach $4,700 in out-of-pocket covered prescription drug costs.
*50% - After Pharma Discount.
**50% of co-pay (Pharma Discount)
|
|
Generic Drugs
|
86%
|
$5.00
|
$5.00
|
|
Preferred Brand Drugs
|
100%*
|
100%*
|
$80.00**
|
|
Brand Drugs
|
100%*
|
100%*
|
$140.00**
|
|
Specialty Drugs
|
100%*
|
100%*
|
$200.00**
|
|
|
Mail Order
|
Pharmacy
|
Mail Order
|
Pharmacy
|
Mail Order
|
Pharmacy
|
|
Generic Drugs
|
86%
|
86%
|
$10.00
|
$12.50
|
$10.00
|
$12.50
|
|
Preferred Brand Drugs
|
100%*
|
100%*
|
100%*
|
100%*
|
$160.00**
|
$165.00**
|
|
Brand Drugs
|
100%*
|
100%*
|
100%*
|
100%*
|
$280.00**
|
$290.00**
|
|
Specialty Drugs
|
100%*
|
100%*
|
100%*
|
100%*
|
$400.00**
|
$400.00**
|
|
|
|
CATASTROPHIC COVERAGE
|
|
After member's yearly out-of-pocket covered prescription drug costs reach $4,700, member pays the greater of:
|
Generic Drugs including
Brands treated as Generic
|
$2.60
|
$2.60
|
$2.60
|
|
All Others
|
$6.50
|
$6.50
|
$6.50
|
|
or the greater of:
|
5% of co-insurance
|
5% of co-insurance
|
5% of co-insurance
|
|
|
|
These plans over a 90-day supply from the Retail Pharmacy as well as Mail Order. This is done through an additional cost
sharing incentive to move members with maintenance medications to Mail Order. After you have received the equivalent of
a 90-day supply (or 3 refills) within a 180-day period, you will be responsible for the higher co-pays above. After the 3rd refill
of maintenance medication, members who have not moved their prescription to Mail Order will pay 40% of the discounted
price of the drug with a minimum that varies by plan. If the discounted drug is less than the minimum, the member pays the
higher amount.
|
|
|
|
Part D Late Enrollment Penalty
|
|
Prescription coverage is offered through Medco Containment Life Insurance Company
|
|
|
