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Your plan benefits coverage for what Medicare does not pay
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Plan Benefits for Level 1
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Monthly Premium
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Deductible
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Generic drug copay
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Preferred brand name drug copay
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Non-preferred brand name drug copay
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Gap Coverage
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Medi-Pak Rx
Basic
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Medi-Pak Rx
Classic
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Medi-Pak Rx
Premier
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$25.90
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$57.20
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$86.50
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$200
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$0
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$0
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$6
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$6
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$5
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$36
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$36
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$36
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$76
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$76
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$76
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You pay 100%
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You pay 100%
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$5 copay,
Generics Only
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|
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The benefit information provided above is a brief summary, but not a comprehensive description of available benefits. Additional information about benefits is available to assist you in making a decision about your coverage. This is an advertisement; for more information, contact a benefits specialist.
S5795_Rx_REV Website Submission (12/07/09)
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