|
| Plan Benefits |
Signature |
Classic |
| Mo Premium |
$41.50 |
$34.40 |
| Deductible |
$0 |
$295 on brand names |
| Tier 1 (generics) |
$0 |
$0 copay |
| Tier 2 (Non-preferred generic) |
$39
copay |
$41 copay |
| Tier 3 (preferred brand) |
$79
copay |
$87 copay |
| Tier 4 (Specialty) |
33% |
25% |
| Coverage Gap* |
None |
None |
| Tier 1 (generics) |
100% |
100% |
| Tier 2 (Non-preferred generic) |
100% |
100% |
|
|
|
| Catastrophic Coverage** |
$2.40 or $6 copay |
$2.40 or $6 copay |
| after yearly costs reach $4,350 |
Or 5% of costs |
Or 5% of costs |
|
|
|
| Mail Order (90 day supplies***) |
|
|
| Tier 1 (generics) |
$0
copay |
$0 copay |
| Tier 2 (Non-preferred generic) |
$117
copay |
$99 copay |
| Tier 3 (preferred brand) |
$237
copay |
$261 copay |
| Tier 4 (Specialty) |
33% |
25% |
|
|
|
|
|
|
| * after yearly drug costs reach $2,700 you pay 100% |
|
|
| ** after yearly drug costs reach $4,350 |
|
|
| ***applies to preferred mail order pharmacy |
|
|
|
