Medica PDP Coverage Stand Alone PDP Product Fact Sheet

Medica Part D Rider (modified standard Rx):

n       Premium = $26.70

n       Copays are now $12 gen / $32 pref brand / $63 non pref brand / 25% specialty

n       Pharmacy benefit levels are changed

            •          Level 1: 0  to $2,510 in total drug costs

            •          Level 2: up to $4,050 in TrOOP Costs

            •          Level 3:  after $4,050 in TrOOP copays are $2.25 for generic (including brand drugs treated as generic) and $5.60 for all other drugs, or 5% coinsurance 

Medica Part D Rider – Enhanced Rx:

n       Premium: $38.90

n       Rider with generic coverage ($10 copay) in the doughnut hole

n       Level 1: 0  to $2,510 in total drug costs:

•          Copays - $10 / $30 / $60 / 25%

n       Level 2: up to $4,050 in TrOOP Costs

•          Copay - $10 generic only

n       Level 3:  after $4,050 in TrOOP, copays are $2.25 for generic (including brand drugs treated as generic) and $5.60 for all other drugs, or 5 % coinsurance 

Mail Order is available for prescriptions through BioScrip 800-677-4323 or Walgreens 800-635-3070.  The member only pays two copays for a 93-day supply.