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| Medica Part D FAQ |
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Medica Part D Optional Coverage Riders call 1-877-800-7340 Modified Standard Rx Medica_Medicare_Product_Brochure.pdf $26.70 per monthCoverage Information LEVEL ONE Coverage Shared Drug Costs 31-Day Supply (Retail) You Pay 90-Day Supply (Mail Order) You Pay • $12 copay for generic drugs • $32 copay for preferred brand-name drugs • $63 copay for non-preferred brand-name drugs • 25% coinsurance for specialty drugs (e.g. injectables, biologicals) • $24 copay for generic drugs • $64 copay for preferred brand-name drugs • $126 copay for non-preferred brand-name drugs • 25% coinsurance for specialty drugs (e.g. injectables, biologicals) Medica Pays All remaining charges LEVEL THREE Coverage $4,050 and up The greater amount of: • $2.25 copay for generic drugs (including brand-name drugs treated as generic drugs) and $5.60 copay for all other drugs; or • 5% coinsurance All remaining charges LEVEL TWO Coverage Up to $4,050 in member out-of-pocket drug costs • 100% of drug costs
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