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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 |
$275* |
$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 |
25% coinsurance** |
$5 copayment** |
$5 copayment** |
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For Preferred Brand Drugs |
25% coinsurance** |
$32 copayment** |
$30 copayment** |
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For Non-Preferred Brand Drugs |
Not Covered† |
$64 copayment** |
$60 copayment** |
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For Specialty Drugs |
25% coinsurance |
33% coinsurance |
33% coinsurance |
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Once YOU and the Medi-Pak Rx plan you've chosen pay this amount, you move
to Level 2. |
$2,510 |
$2,450 |
$2,510 |
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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 copayment** |
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For Preferred Brand Drugs and Specialty Drugs |
100%* |
100%* |
100%* |
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For Non-Preferred Brand Drugs |
Not Covered† |
100%* |
100%* |
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You remain in Level 2 until your True Out-of-Pocket (TrOOP) reaches $4,050. The $4,050
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 and Specialty Drugs |
$2.25 for Generic
(including brand drugs
treated as generic) and
$5.60 for Preferred Brand
and Specialty drugs,
or 5% coinsurance,
whichever is greater. |
$2.25 for Generic
(including brand drugs
treated as generic) and
$5.60 for Preferred Brand
and Specialty drugs,
or 5% coinsurance,
whichever is greater. |
$2.25 for Generic
(including brand drugs
treated as generic) and
$5.60 for Preferred Brand
and Specialty drugs,
or 5% coinsurance,
whichever is greater. |
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For Non-Preferred Brand Drugs |
Not Covered† |
$5.60 for Non-
Preferred Brand drugs,
or 5% coinsurance,
whichever is greater. |
$5.60 for Non-
Preferred Brand drugs,
or 5% coinsurance,
whichever is greater. |
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MONTHLY PREMIUM |
$17.30 |
$38.20 |
$63.50 |
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Formulary |
Standard*** |
Enhanced*** |
Enhanced*** |
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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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** |
A 34-day supply. |
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*** |
The Enhanced Formulary covers more preferred brand-name drugs than the Standard
Formulary. The Enhanced Formulary covers non-preferred brand-name drugs. The Standard
Formulary does not. For more information, review the
Frequently Asked Questions. |
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† |
Drugs that are not covered do not count toward your TrOOP. |