• Overview
• Plan Comparisons
• 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 Plus Plan with Optional POS Plan's Part D Prescription Benefit

DEDUCTIBLE

Tier 1 Formulary Generic	Tier 2 Formulary Preferred Brand	Tier 3 Formulary Non-Preferred Brand	Tier 4 Injectable	Tier 5 Benzodiazepine/ Phenobarbital/ Cough Supp & Vitamins (Not Covered by Medicare*)
$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 $2,510

	Tier 1 Formulary Generic	Tier 2 Formulary Preferred Brand	Tier 3 Formulary Non-Preferred Brand	Tier 4 Injectable	Tier 5 Benzodiazepine/Phenobarbital/ Cough Supp & Vitamins (Not Covered by Medicare*)
Preferred Pharmacy (31-day supply)	$4 copay	25% coinsurance	50% coinsurance	25% coinsurance	$10*
Non-Preferred Pharmacy (31-day supply)	$10 copay	50% coinsurance	75% coinsurance	Not Covered	Not Coverred
Mail Order (93-day supply)	$9 copay	25% coinsurance	50% coinsurance	25% coinsurance	$10*
Long-Term Care Pharmacy (31-day supply)	$4 copay	25% coinsurance	50% coinsurance	25% coinsurance	$10*

COVERAGE GAP
What you pay after the total yearly drug costs reach $2,510 and before the yearly out-of-pocket drug costs reach $4,050

	Formulary Generic	Tier 2 Formulary Preferred Brand	Tier 3 Formulary Non-Preferred Brand	Tier 4 Injectable	Tier 5 Benzodiazepine/Phenobarbital/ Cough Supp & Vitamins (Not Covered by Medicare*)
Preferred Pharmacy (31-day supply)	$4 copay	100%	100%	100%	$10*
Non-Preferred Pharmacy (31-day supply)	$10 copay	100%	100%	Not Covered	Not Coverred
Mail Order (93-day supply)	$9 copay	100%	100%	100%	$10*
Long-Term Care Pharmacy (31-day supply)	$4 copay	100%	100%	100%	$10*

CATASTROPHIC COVERAGE
What you pay after the yearly out-of-pocket drugs cost $4,050

Tier 1 Formulary Generic	Tier 2 Formulary Preferred Brand	Tier 3 Formulary Non-Preferred Brand	Tier 4 Injectable	Tier 5 Benzodiazepine/Phenobarbital/ Cough Supp & Vitamins (Not Covered by Medicare*)
Greater of $2.25 or 5% coinsurance	Greater of $5.60 or 5% coinsurance	Greater of $5.60 or 5% coinsurance	Greater of $5.60 or 5% coinsurance	$10*

* Tier 5 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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