|
| Plan Benefits |
Plan One |
Plan Two |
Plan Three |
| Mo Premium |
$36.30 |
$49.80 |
$80.10 |
| Deductible |
$295 |
$0 |
$0 |
| Tier 1 (generics) |
$2-3
copay |
$0 copay |
$6
copay |
| Tier 2 (Non-preferred generic) |
$25-33
copay |
$6 copay |
$35
copay |
| Tier 3 (preferred brand) |
$60-95
copay |
$33-47 copay |
$60
copay |
| Tier 4 (Specialty) |
25% |
$75-88 copay |
33% |
| Tier 5 |
n/a |
33% |
n/a |
| Coverage Gap* |
None |
None |
Yes |
| Tier 1 (generics) |
100% |
100% |
25%
of costs |
| Tier 2 (Non-preferred generic) |
100% |
100% |
100% |
|
|
|
|
| Catastrophic Coverage** |
|
|
|
| after yearly costs reach $4,350 |
5% of costs |
5% of costs |
5% of costs |
|
|
|
|
| Mail Order (90 day supplies***) |
|
|
|
| Tier 1 (generics) |
$6.25
copay |
$0 copay |
$15 copay |
| Tier 2 (Non-preferred generic) |
$82.50
copay |
$15 copay |
$87.50 copay |
| Tier 3 (preferred brand) |
$200
copay |
$95 copay |
$150 copay |
| Tier 4 (Specialty) |
25.00% |
$200 copay |
33% |
|
|
|
|
|
|
|
|
| * after yearly drug costs reach $2,700 you pay 100% |
|
|
|
| ** after yearly drug costs reach $4,350 |
|
|
|
| ***applies to preferred mail order pharmacy |
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|
