First UA Part D Silver Deductibles and Premiums
STATE | DEDUCTIBLE | MONTHLY PREMIUM |
NY |
$160
|
$38.20
|
What Do You and First UA Medicare Part D Silver Pay?
$160 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. |
|
$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 Silver plan pays 95% of your drug costs; you pay 5%. During catastrophic coverage you 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?
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 | $45 | $135 | $45 | $112.50 |
$45
|
| Nonpreferred Brands Tier 3 | $90 | $270 | $90 | $225 |
$90
|
| Specialty Brands Tier 4 | 25% | 25% | 25% | 25% |
25%
|
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 may be 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% | $29.90 |
| 50% | $21.50 |
| 75% | $13.20 |
| 100% | $4.90 |
*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: 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 click here for our customer service contact information.
