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. With the UPMC for Life HMO Rx plan you have additional coverage for generic drugs in Tier 1 and Tier 2 while in the Coverage Gap Stage. You will continue to pay the same drug copays in the Coverage Gap Stage for Tier 1 and Tier 2 generic prescription drugs that you paid in the Initial Coverage Stage. For all other drugs, the coverage gap discount listed in the first paragraph applies. 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 16 HMO Summary of Benefits 69