UA Medicare Part D

UA Part D Premiums

Premiums vary by state.

STATE	DEDUCTIBLE	MONTHLY PREMIUM
	$0	$

What Does UA Medicare Part D Pay?

$4,350	Catastrophic Coverage	Catastrophic coverage begins when you have spent $4,350 on drugs. For the rest of the year, your UA Medicare Part D plan pays 95% of your drug costs; you pay 5%. During catastrophic coverage you will pay the greater of $2.40 for generic drugs or drugs that are treated like generics, and $6 for all other drugs or 5% coinsurance. We will pay the rest.
$2,700	The Coverage Gap (The Donut Hole)	The coverage gap begins when you and UA have spent $2,700 on drugs. Now you pay for 100% of your prescriptions.
No deductible Copays vary by state	Initial Coverage	UA Part D has no deductible. Copays for generic drugs start at $5.

Explanation of Benefits

You will receive an Explanation of Benefits (EOB) for every claim. The EOB will show you what drug costs we covered. The EOB also tracks your spending and ours, so you always know how close you are to the gap.

2009 Low Income Subsidy (LIS) Information

If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our plan.

Click Here to see what your monthly premium will be if you get help.

updated 10/01/08

DRUG TIER	Retail In-Network Pharmacy 34-Day Supply Copayment / Coinsurance	Retail In-Network Pharmacy 90-Day Supply Copayment / Coinsurance	Retail Out-of-Network Pharmacy 34-Day Supply Copayment / Coinsurance	Mail Order 90-Day Supply Copayment / Coinsurance	Out-of-Network Pharmacy Copayment/ Coinsurance (34-day supply)
Generics Tier 1	$5	$14	$5	$13	$5
Preferred Brands Tier 2	$31	$78	$31	$62	$31
Non-Preferred Brands Tier 3	$62	$155	$62	$124	$62
Specialty Brands Tier 4	33%	33%	33%	33%	33%

DRUG TIER	Retail In-Network Pharmacy 34-Day Supply Copayment / Coinsurance	Retail In-Network Pharmacy 90-Day Supply Copayment / Coinsurance	Retail Out-of-Network Pharmacy 34-Day Supply Copayment / Coinsurance	Mail Order 90-Day Supply Copayment / Coinsurance	Out-of-Network Pharmacy Copayment/ Coinsurance (34-day supply)
Generics Tier 1	$6	$17	$6	$15	$6
Preferred Brands Tier 2	$32	$80	$32	$64	$32
Non-Preferred Brands Tier 3	$64	$160	$64	$128	$64
Specialty Brands Tier 4	33%	33%	33%	33%	33%

DRUG TIER	Retail In-Network Pharmacy 34-Day Supply Copayment / Coinsurance	Retail In-Network Pharmacy 90-Day Supply Copayment / Coinsurance	Retail Out-of-Network Pharmacy 34-Day Supply Copayment / Coinsurance	Mail Order 90-Day Supply Copayment / Coinsurance	Out-of-Network Pharmacy Copayment/ Coinsurance (34-day supply)
Generics Tier 1	$7	$20	$7	$18	$7
Preferred Brands Tier 2	$33	$83	$33	$66	$33
Non-Preferred Brands Tier 3	$66	$165	$66	$132	$66
Specialty Brands Tier 4	33%	33%	33%	33%	33%

DRUG TIER	Retail In-Network Pharmacy 34-Day Supply Copayment / Coinsurance	Retail In-Network Pharmacy 90-Day Supply Copayment / Coinsurance	Retail Out-of-Network Pharmacy 34-Day Supply Copayment / Coinsurance	Mail Order 90-Day Supply Copayment / Coinsurance	Out-of-Network Pharmacy Copayment/ Coinsurance (34-day supply)
Generics Tier 1	$9	$25	$9	$23	$9
Preferred Brands Tier 2	$35	$88	$35	$70	$35
Non-Preferred Brands Tier 3	$70	$175	$70	$140	$70
Specialty Brands Tier 4	33%	33%	33%	33%	33%

Getting Started

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UA Part D Premiums

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