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• Medvantage Plan
• Medvantage Plan with Optional Point of Service Benefit
• Medvantage Rx Plan
  • Part D Prescription Benefit
• Medvantage Rx Plan with Optional Point of Service Benefit
  • Part D Prescription Benefits
• Medvantage Rx Plus Plan
  • Part D Prescription Benefit
• Medvantage Rx Plus Plan with Optional Point of Service Benefit
  • Part D Prescription Benefit

Medvantage Rx Plan with Optional POS Plan's Part D Prescription Benefits

DEDUCTIBLE

Tier 1 Formulary Preferred Generic	Tier 2 Formulary Non-Preferred Generic	Tier 3 Formulary Preferred Brand	Tier 4 Formulary Non-Preferred Brand	Tier 5 Injectable	Tier 6 Speciality Drugs	Tier 7 Enhanced Medicare (Benzodiazepine/ Phenobarbital / Cough Supp & Vitamin - Not Covered by Medicare*)
$136						NOT COVERED

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 $2,830

	Tier 1 Formulary Preferred Generic	Tier 2 Formulary Non-Preferred Generic	Tier 3 Formulary Preferred Brand	Tier 4 Formulary Non-Preferred Brand	Tier 5 Injectable	Tier 6 Specialty Drugs	Tier 7 Enhanced Medicare (Benzodiazepine / Phenobarbital / Cough Supp & Vitamin - Not Covered by Medicare*)
Preferred Pharmacy (31-day supply)	20% coinsurance	20% coinsurance	$40 copay	$70 copay	25% coinsurance	29% coinsurance	Not Covered
Non-Preferred Pharmacy (31-day supply)	30% coinsurance	30% coinsurance	$50 copay	$80 copay	25% coinsurance	29% coinsurance	Not Covered
Mail Order (93-day supply)	20% coinsurance	20% coinsurance	$117 copay	$207 copay	25% coinsurance	29% coinsurance	Not Covered
Long-Term Care Pharmacy (31-day supply)	30% coinsurance	30% coinsurance	$50 copay	$80 copay	25% coinsurance	29% coinsurance	Not Covered

COVERAGE GAP (the plan covers ALL Formulary Generics through the coverage gap)
What you pay after the total yearly drug costs reach $2,830 and before the yearly out-of-pocket drug costs reach $4,550

Tier 1 Formulary Preferred Generic	Tier 2 Formulary Non-Preferred Generic	Tier 3 Formulary Preferred Brand	Tier 4 Formulary Non-Preferred Brand	Tier 5 Injectable	Tier 6 Specialty Drugs	Tier 7 Enhanced Medicare (Benzodiazepine/ Phenobarbital / Cough Supp & Vitamin - Not Covered by Medicare*)
100%	100%	100%	100%	100%	100%	Not Covered

CATASTROPHIC COVERAGE
What you pay after the yearly out-of-pocket drugs cost $4,550

Tier 1 Formulary Preferred Generic	Tier 2 Formulary Non-Preferred Generic	Tier 3 Formulary Preferred Brand	Tier 4 Formulary Non-Preferred Brand	Tier 5 Injectable	Tier 6 Speciality Drugs	Tier 7 Enhanced Medicare (Benzodiazepine / Phenobarbital Cough Supp & Vitamins - Not Covered by Medicare*)
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	Not Covered

* Tier 7 Drugs do not count towards your total out-of-pocket expenditure. If you are receiving extra help to pay for your prescriptions, you will not receive any extra help to pay for these drugs. In addition, Tier 5 drugs are available at Preferred Pharmacies only for a 31 day supply.

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DISCLAIMER: The benefit information provided herein is a brief summary, but not a comprehensive description of available benefits. Additional information about benefits is available to assist you in making a decision about your coverage. This is an advertisement; for more information contact Florida Health Care Plans.