UA Medicare Part D

Part D Premiums

Premiums vary by state.

STATE	DEDUCTIBLE	MONTHLY PREMIUM
	$0	$

What Do You and UA Medicare Part D Pay?

No deductible; copays vary by state	Initial Coverage	UA Medicare Part D has no deductible. Copays for generic drugs start at $6 .
$2,830	The Coverage Gap (The Donut Hole)	The coverage gap begins when you and the Company have spent $2,830 on drugs. Now you pay for 100% of your prescriptions.
$4,550	Catastrophic Coverage	Catastrophic coverage begins when you have spent $4,550 on drugs. For the rest of the year, your Medicare Part D plan pays 95% of your drug costs; you pay 5%. During catastrophic coverage you pay the greater of $2.50 for generic drugs or drugs that are treated like generics, and $6.30 for all other drugs or 5% coinsurance. We pay the rest.

Explanation of Benefits

You receive an Explanation of Benefits (EOB) each month in which you have a claim. The EOB shows 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.

2010 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 is lower than what it would be if you did not get extra help from Medicare. The amount of extra help you get determines 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 10/1/09

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
Generics Tier 1	$6	$17	$6	$15
Preferred Brands Tier 2	$35	$88	$35	$70
Non-Preferred Brands Tier 3	$70	$175	$70	$140
Specialty Brands Tier 4	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
Generics Tier 1	$7	$20	$7	$18
Preferred Brands Tier 2	$36	$90	$36	$72
Non-Preferred Brands Tier 3	$72	$180	$72	$144
Specialty Brands Tier 4	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
Generics Tier 1	$8	$23	$8	$21
Preferred Brands Tier 2	$37	$93	$37	$74
Non-Preferred Brands Tier 3	$74	$185	$74	$148
Specialty Brands Tier 4	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
Generics Tier 1	$9	$25	$9	$23
Preferred Brands Tier 2	$38	$95	$38	$76
Non-Preferred Brands Tier 3	$76	$190	$76	$152
Specialty Brands Tier 4	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
Generics Tier 1	$10	$28	$10	$26
Preferred Brands Tier 2	$39	$98	$39	$78
Non-Preferred Brands Tier 3	$78	$195	$78	$156
Specialty Brands Tier 4	33%	33%	33%	33%

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Part D Premiums

How much are my copays?