First UA Part D Premiums
STATE | DEDUCTIBLE | MONTHLY PREMIUM |
NY | $0 | $39.20 |
What Does First 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 First 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 First UA have spent $2,510 on drugs. Now you pay for 100% of your prescriptions. |
No deductibles | Initial Coverage |
First 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.
How much are my co-pays?
First UA Medicare Part D (no deductible; $37 co-payment)
State of New York
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% |
updated 10/01/07
