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With Medi-Pak Rx®
BASIC, YOU pay: |
With Medi-Pak Rx
CLASSIC, YOU pay: |
With Medi-Pak Rx
PREMIER, YOU pay: |
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Level 1
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Deductible |
$185* |
$0 |
$0 |
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After the Level 1 deductible has been satisfied (if applicable), then YOU pay: |
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For generic drugs |
$5 copay** |
$5 copay** |
$5 copay** |
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For preferred brand drugs |
$30 copay** |
$30 copay** |
$30 copay** |
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For non-preferred brand drugs |
$68 copay** |
$68 copay** |
$68 copay** |
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For specialty drugs |
25% coinsurance |
25% coinsurance |
25% coinsurance |
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Once YOU and the Medi-Pak Rx plan you've chosen pay this amount, you move
to Level 2. |
$2,700 |
$2,700 |
$2,700 |
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Level 2
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In the "coverage gap" (Level 2), YOU pay: |
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For generic drugs |
100%* |
100%* |
$5 copay** |
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For preferred brand, non-preferred brand and specialty drugs |
100%* |
100%* |
100%* |
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You remain in Level 2 until your True Out-of-Pocket (TrOOP) reaches $4,350. The $4,350
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.) Then you move
to Level 3. |
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Level 3
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Once in Level 3, for the remainder of the calendar year, YOU pay: |
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For generic, preferred brand, non-preferred brand and specialty drugs |
$2.40 for generic
(including brand drugs
treated as generic) and
$6 for preferred brand,
non-preferred brand and
specialty drugs, or 5%
coinsurance, whichever is greater. |
$2.40 for generic
(including brand drugs
treated as generic) and
$6 for preferred brand,
non-preferred brand and
specialty drugs, or 5%
coinsurance, whichever is greater. |
$2.40 for generic
(including brand drugs
treated as generic) and
$6 for preferred brand,
non-preferred brand and
specialty drugs, or 5%
coinsurance, whichever is greater. |
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MONTHLY PREMIUM |
$21.60 |
$39.60 |
$64.90 |
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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. |
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* |
Important Note: Even when you're responsible for 100 percent of the cost
of drugs, you will still pay less because you'll benefit from our negotiated discount
prices. |
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** |
34-day supply. |
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† |
Prescription drugs that are not covered do not count toward your TrOOP. |
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