Medvantage Rx Plan's Part D Prescription Benefits

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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
$150
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)		 20% coinsurance 20% coinsurance 25% coinsurance 50% coinsurance 25% coinsurance 29% coinsurance
Non-Preferred Pharmacy
(31-day supply)		 30% coinsurance 30% coinsurance 50% coinsurance 75% coinsurance 25% coinsurance 29% coinsurance
Mail Order
(93-day supply)		 20% coinsurance 20% coinsurance 25% coinsurance 50% coinsurance 25% coinsurance 29% coinsurance
Long-Term Care Pharmacy
(31-day supply)		 30% coinsurance 30% coinsurance 50% coinsurance 75% coinsurance 25% coinsurance 29% coinsurance
COVERAGE GAP
After your total yearly drug costs reach $2,840, you receive a discount on brand name drugs and pay 93% of the plan’s costs until your yearly out of pocket drug costs reach $4,550.
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