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. 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. Make sure your drugs are covered. To make sure your drugs are covered and check your costs, you can search for them at upmchp.us/prescription-coverage or give us a call at the phone number on page 4. You can also view your plan’s formulary at upmchp.us/documents. Save money on your drugs by filling at a preferred pharmacy. To find a preferred pharmacy, call us or go to upmchealthplan.com/find. upmchealthplan.com/medicare 10 HMO Summary of Benefits 47