Medvantage Rx Plus Plan's Part D Prescription Benefit

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DEDUCTIBLE
Tier 1
Preferred Generic Drugs		 Tier 2
Non-Preferred Generic Drugs 		Tier 3
Preferred Brand Drugs		 Tier 4
Non-Preferred Brand Drugs 		Tier 5
Injectable Drugs 		Tier 6
Specialty Tier Drugs
$0
INITIAL COVERAGE LEVEL
What you pay after your yearly deductible is met and before the yearly total drug costs (paid by both you and the plan) reach $2,840
 Tier 1
Preferred Generic Drugs		 Tier 2
Non-Preferred Generic Drugs		 Tier 3
Preferred Brand Drugs		 Tier 4
Non-Preferred Brand Drugs 		Tier 5
Injectable Drugs 		Tier 6
Specialty Tier Drugs
Preferred Pharmacy
(31-day supply)		 $4 copay $7 copay 25% coinsurance 50% coinsurance 25% coinsurance 33% coinsurance
Non-Preferred Pharmacy
(31-day supply)		 $11 copay $17 copay 50% coinsurance 75% coinsurance 25% coinsurance 33% coinsurance
Mail Order
(93-day supply)		 $9 copay $18 copay 25% coinsurance 50% coinsurance 25% coinsurance 33% coinsurance
Long-Term Care Pharmacy
(31-day supply)		 $11 copay $17 copay 50% coinsurance 75% coinsurance 25% coinsurance 33% coinsurance
COVERAGE GAP
After your total yearly drug costs reach $2,840, you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 93% of the plan’s costs for generic drugs until your yearly out-of-pocket drug costs reach $4,550.
  Tier 1
Preferred Generic Drugs		 Tier 2
Non-Preferred Generic Drugs		 Tier 3
Preferred Brand Drugs		 Tier 4
Non-Preferred Brand Drugs 		Tier 5
Injectable Drugs 		Tier 6
Specialty Tier Drugs
Preferred Pharmacy
(31-day supply)		 $4 copay $7 copay Not Covered Not Covered Not Covered Not Covered
Non-Preferred Pharmacy
(31-day supply)		 $11 copay $17 copay Not Covered Not Covered Not Covered Not Covered
Mail Order
(93-day supply)		 $9 copay $18 copay Not Covered Not Covered Not Covered Not Covered
Long-Term Care Pharmacy
(31-day supply)		 $11 copay $17 copay Not Covered Not Covered Not Covered Not Covered
CATASTROPHIC COVERAGE
What you pay after the yearly out-of-pocket drugs cost $4,550
Tier 1
Preferred Generic Drugs		 Tier 2
Non-Preferred Generic Drugs		 Tier 3
Preferred Brand Drugs		 Tier 4
Non-Preferred Brand Drugs 		Tier 5
Injectable Drugs 		Tier 6
Specialty Tier Drugs
Greater of $2.50 or 5% coinsurance Greater of $2.50 or 5% coinsurance Greater of $6.30 or 5% coinsurance Greater of $6.30 or 5% coinsurance Greater of $6.30 or 5% coinsurance Greater of $6.30 or 5% coinsurance