First UA Part D Silver Deductibles and Premiums
STATE | DEDUCTIBLE | MONTHLY PREMIUM |
NY | $130 | $34.30 |
What Does First UA Medicare Part D Silver 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 Silver 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. |
$130 deductible on all drugs except generic drugs | Initial Coverage |
First UA Part D Silver has a deductible that must be met on all drugs, except generics. After you meet your deductible for non-generic drugs, you pay the co-pay for the prescriptions you receive. For generic drugs, you only pay the $4 co-pay. |
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?
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 | $4 | $12 | $4 | $10 |
| Preferred Brands Tier 2 | $40 | $120 | $40 | $100 |
| Non-Preferred Brands Tier 3 | $80 | $240 | $80 | $200 |
| Specialty Brands Tier 4 | 25% | 25% | 25% | 25% |
updated 10/01/07
