First UA Part D Silver Deductibles and Premiums
STATE | DEDUCTIBLE | MONTHLY PREMIUM |
NY |
$150
|
$38.80
|
What Does First UA Medicare Part D Silver Pay?
|
$4,350
|
Catastrophic Coverage |
Catastrophic coverage begins when you have spent $4,350 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 $2.40 for generic drugs or drugs that are treated like generics, and $6 for all other drugs or 5% coinsurance. We will pay the rest. |
|
$2,700
|
The Coverage Gap (The Donut Hole) |
The coverage gap begins when you and First UA have spent $2,700 on drugs. Now you pay for 100% of your prescriptions. |
$150 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 nongeneric drugs, you pay the copay for the prescriptions you receive. For generic drugs, you only pay the $4 copay. |
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 copays?
State of New York
DRUG TIER | Retail In-Network Pharmacy
34-Day Supply Copayment / Coinsurance |
Retail In-Network Pharmacy
90-Day Supply Copayment / Coinsurance Retail |
Out-of-Network Pharmacy
34-Day Supply Copayment / Coinsurance |
Mail Order
90-Day Supply Copayment / Coinsurance |
Out-of-Network
Pharmacy Copayment/ Coinsurance (34-day supply) |
| Generics Tier 1 | $4 | $12 | $4 | $10 |
$4
|
| Preferred Brands Tier 2 | $40 | $120 | $40 | $100 |
$40
|
| Nonpreferred Brands Tier 3 | $80 | $240 | $80 | $200 |
$80
|
| Specialty Brands Tier 4 | 25% | 25% | 25% | 25% |
25%
|
2009 Low Income Subsidy (LIS) Information
If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our plan.
This table shows you what your monthly plan premium will be if you get extra help.
LEVEL OF HELP | MONTHLY PREMIUM* |
| 100% | $0.00 |
| 75% | $11.65 |
| 50% | $19.40 |
| 25% | $29.10 |
*This does not include any Medicare Part B premium you may have to pay.
If you aren’t getting extra help, you can see if you qualify by calling:
- 800-Medicare/800-633-4227 (TTY/TTD: 877-486-2048)
- Your state Medicaid office
- Or, the Social Security Administration at 800-772-1213 (TTY/TTD: 800-325-0778)
If you have any questions, please click here for our customer service contact information.
