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Plan Benefits
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With Basic,
YOU pay:
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With Classic,
YOU pay:
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With Premier,
YOU pay:
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Monthly Premium
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$25.90
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$57.20
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$86.50
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Deductible
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$200
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$0
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$0
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Generic drug copay
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$6
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$6
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$5
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Preferred brand name drug copay
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$36
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$36
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$36
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Non-preferred brand name drug copay
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$76
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$76
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$76
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Specialty drugs
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25%
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25%
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25%
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You move to Level 2 once YOU and the Medi-Pak Rx plan you have chosen pay $2,830.
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Generic drugs
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100%*
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100%*
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$5 copay**
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For preferred brand,
non-preferred brand and specialty drugs
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100%*
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100%*
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100%*
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You move to Level 3 after your True Out-of-Pocket (TrOOP) reaches $4,550. The $4,550 includes your deductible, if applicable, plus the amount YOU (not Medi-Pak Rx) paid in Level 1 and Level 2†. (To ensure your TrOOP is captured accurately, use network pharmacies that will file your claims electronically.)
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For generic drugs
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$2.50 or 5% coinsurance, whichever is greater.
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$2.50 or 5% coinsurance, whichever is greater.
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$2.50 or 5% coinsurance, whichever is greater.
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For preferred brand,
non-preferred brand and specialty drugs
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$6.30 or 5% coinsurance, whichever is greater.
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$6.30 or 5% coinsurance, whichever is greater.
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$6.30 or 5% coinsurance, whichever is greater.
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You remain in Level 3 the remainder of the calendar year.
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Remember, you must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third party.
* Important Note: Even when you’re responsible for 100% of the cost of prescription drugs in Level 2, you still pay less because you’ll benefit from our negotiated discount prices.
** 34-day supply.
† Prescription drugs that are not covered do not count toward your TrOOP.
The benefit information provided above is a brief summary, but not a comprehensive description of available benefits. Additional information about benefits is available to assist you in making a decision about your coverage. This is an advertisement; for more information, contact a benefits specialist.
S5795_Rx_REV Website Submission (12/07/09)
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