First UA Part D Premiums

STATE
DEDUCTIBLE
MONTHLY PREMIUM
NY
$0
$46.00

What Does First UA Medicare Part D Pay?

No deductibles

Initial Coverage
First UA Part D has no deductible.  Copays for generic drugs start at $10.
$2,830
The Coverage Gap
(The Donut Hole)
The coverage gap begins when you and First UA have spent $2,830 on drugs.  Now you pay for 100% of your prescriptions.
$4,550
Catastrophic Coverage
Catastrophic coverage begins when you have spent $4,550 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 $2.50 for generic drugs or drugs that are treated like generics, and $6.30 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.

How much are my copays?

First UA Medicare Part D
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
$10
$28
$10
$26
$10
Preferred Brands
Tier 2
$39
$98
$39
$78
$39
Nonpreferred Brands
Tier 3
$78
$195
$78
$156
$78
Specialty Brands
Tier 4
33%
33%
33%
33%
33%

2010 Low Income Subsidy (LIS) Information

If you get extra help from Medicare to pay for your Medicare prescription drug plan costs, your monthly plan premium is lower than what it would be if you did not get extra help from Medicare. The amount of extra help you get determines your total monthly plan premium as a member of our plan.

This table shows you what your monthly plan premium is if you get extra help.

LEVEL OF HELP
MONTHLY PREMIUM*
25% $37.70
50% $29.30
75% $21.00
100% $12.70

*This does not include any Medicare Part B premium you may have to pay.

If you aren’t getting extra help, see if you qualify by calling:

If you have any questions, please click here for our customer service contact information.

updated 10/1/09

This website is intended to provide you with information about Medicare prescription drug coverage so you can make an informed decision about how Medicare Part D can help you manage your prescription drug costs. First United American Life Insurance Company is a Medicare-approved Part D sponsor.