UA Part D Premiums
Premiums vary by state.
STATE | DEDUCTIBLE | MONTHLY PREMIUM |
|
| $0 | $ |
How much are my co-pays?
UA Medicare Part D
CT, DC, DE, IA, LA, MA, MD, MI, MN, MO, MT, ND, NE, NJ, PA, RI, SD, VT, WV, WY
DRUG TIER | Retail In-Network Pharmacy
34-Day Supply
Co-Payment / Coinsurance |
Retail In-Network Pharmacy
90-Day Supply
Co-Payment / Coinsurance |
Retail Out-of-Network Pharmacy
34-Day Supply
Co-Payment / Coinsurance |
Mail Order
90-Day Supply
Co-Payment / Coinsurance |
Generics
Tier 1 | $9 | $23 | $9 | $18 |
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% |
How much are my co-pays?
UA Medicare Part D
AR, ID, IN, KS, KY, ME, NH, NM, OH, OR, UT, VA, WA, WI
DRUG TIER | Retail In-Network Pharmacy
34-Day Supply
Co-Payment / Coinsurance |
Retail In-Network Pharmacy
90-Day Supply
Co-Payment / Coinsurance |
Retail Out-of-Network Pharmacy
34-Day Supply
Co-Payment / Coinsurance |
Mail Order
90-Day Supply
Co-Payment / Coinsurance |
Generics
Tier 1 | $9 | $23 | $9 | $18 |
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% |
How much are my co-pays?
UA Medicare Part D
AL, AK, AZ, CA, CO, FL, GA, HI, IL, MS, NC, NV, OK, SC, TN, TX
DRUG TIER | Retail In-Network Pharmacy
34-Day Supply
Co-Payment / Coinsurance |
Retail In-Network Pharmacy
90-Day Supply
Co-Payment / Coinsurance |
Retail Out-of-Network Pharmacy
34-Day Supply
Co-Payment / Coinsurance |
Mail Order
90-Day Supply
Co-Payment / Coinsurance |
Generics
Tier 1 | $9 | $23 | $9 | $18 |
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% |
What Does UA Medicare Part D Pay?
$4,050 |
Catastrophic Coverage |
Catastrophic coverage begins when you have spent $4,050 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 $2.25 for generic drugs or drugs that are treated like generics, and $5.60 for all other drugs or 5% coinsurance. We will pay the rest. |
$2,510 |
The Coverage Gap
(The Donut Hole) | The coverage gap begins when you and UA have spent $2,510 on drugs. Now you pay for 100% of your prescriptions. |
No deductible
Co-pays vary by state
| Initial Coverage |
UA Part D has no deductible. Co-pays for generic drugs start at $9. |
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.
updated 10/01/07
