2022 Lycoming Tioga MA Kit

Coverage gap stage (donut hole) You pay up to 25% of the plan’s cost for brand-name and generic drugs plus a portion of the dispensing fee for brand-name drugs. You remain in this stage until your out-of-pocket costs as well as any manufacturer’s discount payments provided for brand-name drugs reach $7,050. After that you move into the catastrophic coverage stage. Catastrophic coverage stage Once you reach this stage, you pay the greater of 5% or $3.95 for a generic drug (or a drug treated like a generic). For all other drugs, you pay the greater of 5% or $9.85. Get the prescriptions you need and save money $0 preferred generic medications (Tier 1) For all plans during the initial coverage stage Fill your prescription at a preferred pharmacy or preferred mail-order pharmacy, and you’ll have a $0 copay. Lower copays for covered diabetic medications (Tier 2) For the initial coverage stage of all plans except HMO Premier Rx and PPO Flex Rx Save money on covered, brand-name, non-insulin diabetic medications that help lower your blood sugar. • $10 copay for a 30-day supply at a preferred retail pharmacy • $20 copay for a 90-day supply at a preferred pharmacy Save money with donut hole coverage for insulin medications For all plans during the coverage gap stage Your copay is the same in the initial coverage and coverage gap “donut hole” stages, which may save you hundreds! This applies to covered insulins filled at standard, preferred, or mail-order pharmacies. • $35 for a 30-day supply filled at retail pharmacies • $87.50 for a 90-day supply filled at a preferred mail-order pharmacy • $96.25 for a 90-day supply filled at a preferred retail pharmacy • $105 copay for a 90-day supply filled at standard pharmacies Save money on generic drugs in the donut hole (Tier 1 and Tier 2) For HMO Rx members during the coverage gap stage With additional coverage through the coverage gap “donut hole” stage, you will no longer have to pay more for generic drugs on Tier 1 and generic drugs on Tier 2. Generic drugs are listed in lowercase italics . This benefit does not apply to brand-name drugs. • $0 copay for a 30-day supply of Tier 1 generic drugs at a preferred retail pharmacy • $0 copay for a 90-day supply of Tier 1 generic drugs at a preferred pharmacy • $10 copay for a 30-day supply of Tier 2 generic drugs at a preferred retail pharmacy • $20 copay for a 90-day supply of Tier 2 generic drugs at a preferred pharmacy For more information view our full covered drug list at upmchp.us/prescription-coverage. Preferred pharmacies o er low copays for covered prescriptions. This means you will pay less simply by filling your prescriptions at these pharmacies. Search for a preferred retail pharmacy near you at upmchp.us/pharmacy-finder.   Drug List 13