First UA Medicare Part D Premiums for 2011

State	Deductible	Monthly Premium
New York	$110	$49.80

 

What Does First UA Medicare Part D Pay?
Deductible and copay.	Initial Coverage	First UA Part D has a deductible for brand-name drugs. Copays for generic drugs start at $10.
$2,840	The Coverage Gap (The Donut Hole)	After your yearly drug costs reach $2,840, you receive a discount on brand-name drugs and pay 93% of the Plan's costs for all generic drugs, until your yearly out-of-pocket drug costs reach $4,550. If you reach the coverage gap in 2011, you will receive a 50% discount on your brand-name drugs. Click here to learn more.
$4,550	Catastrophic Coverage	After your yearly out-of-pocket drug costs reach $4,550, you pay the greater of: A $2.50 copay for generic (including brand-name drugs treated as generic) and a $6.30 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.

How much are my copays?
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
Generics Tier 1	$10	$28	$10	$26
Preferred Brands Tier 2	$45	$113	$45	$90
Non-Preferred Brands Tier 3	$95	$238	$95	$190
Specialty Brands Tier 4	30%	30%	30%	30%

2011 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%	$40.10
50%	$30.50
75%	$20.80
100%	$11.10

 

*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:

• 1-800-Medicare/1-800-633-4227 (TTY/TDD: 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 click here for our customer service contact information.

 

Updated 10/1/10

FIRST UNITED AMERICAN Part D Prescription Drug Plans