First United American Select Plan (PDP)
Premium & Deductible
| Premium |
Deductible (annual) |
$37.40 (monthly)
|
$320.00 |
Coverage Phases
| Initial Coverage |
Our Select Plan (PDP) has a deductible of $320 (applies to all tiers).
Copays for mail order Preferred Generic drugs start at $0. |
| The Coverage Gap |
$2,930(The Donut Hole) After your yearly drug costs reach $2,930, you receive a discount on brand-name drugs and pay 86% of the Plan's costs for all generic drugs, until your yearly out-of-pocket drug costs reach $4,700. |
| Catastrophic Coverage |
$4,700After your yearly out-of-pocket drug costs reach $4,700, you pay the greater of: A $2.60 copay for generic (including brand-name drugs treated as generic) and a $6.50 copay for all other drugs, or 5% coinsurance. We pay the rest. |
Explanation of Benefits
You receive an Explanation of Benefits (EOB) each month in which you have a claim. The EOB shows 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.
Drug Tiers/Cost Sharing
| 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 |
Preferred Generics
Tier 1 |
$3 |
$9 |
$3 |
$0 |
Non-Preferred Generics
Tier 2 |
$9 |
$27 |
$9 |
$24 |
Preferred Brands
Tier 3 |
$45 |
$135 |
$45 |
$122 |
Non-Preferred Brands
Tier 4 |
$95 |
$285 |
$95 |
$257 |
Specialty
Tier 5 |
25% |
25% |
25% |
25% |
2012 Low Income Subsidy (LIS) Information
If you meet certain income and resource guidelines, you may qualify for Extra Help from Medicare to pay the costs of Medicare prescription drug coverage. If you qualify for Extra Help, your monthly plan premium is lower. The amount of Extra Help you get determines your total monthly plan premium as a member of one of our plans. In addition, your deductible, copays, and coinsurance will be reduced.
This table shows you what your monthly plan premium is if you get Extra Help.
| Level of Help |
Monthly Premium* |
| 25% |
$28.00 |
| 50% |
$18.70 |
| 75% |
$9.30 |
| 100% |
$0.00 |
*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:
1-800-Medicare/1-800-633-4227 (TTY/TDD: 1-877-486-2048)
Your state Medicaid office or, the Social Security Administration at
1-800-772-1213 (TTY/TDD: 1-800-325-0778)
If you have any questions, please contact First UA Customer Service:
Contact Us
Updated 10/01/11