Florida Masterpiece Rx Choice Plan

Outpatient Prescription Drugs

You pay 100% for most prescription drugs, unless you enroll in the Medicare Part D Prescription Drug program

You pay $ 104.89 each month for your Medicare Part D prescription benefits.

This plan does not cover Medicare Part B prescription drugs.

This plan uses a formulary. A formulary is a preferred list of drugs selected to meet patient needs at a lower cost. If the formulary changes, you will be notified, in writing, before the change. To view the plan's formulary, go to www.univhc.com on the web.

People who have low incomes, who live in long term care facilities, or who have access to Indian/Tribal/Urban (Indian Health Service) facilities may have different out-of-pocket drug costs. Contact the plan for details.

There is no deductible

Before the total yearly drug costs (paid by both you and your plan) reach $ 2,250.00, you pay the following for prescription drugs:

• $ 0 for a one-month (30 day) supply of Tier 1 - Preferred Generics – Generic drugs you get at an in-network preferred pharmacy.

• $ 10 for a one-month (30 day) supply of Tier 2 - Generics and Preferred Brands -Generic and Preferred Brand drugs you get at an in-network preferred pharmacy.

•  $ 25 for a one-month (30 day) supply of Tier 3 - Brands - Brand drugs you get at an in-network preferred pharmacy

• 25 % coinsurance for a one-month (30 day) supply of Tier 4 - Injectibles - Generic and Brand drugs you get at an in-network preferred pharmacy.

• 25 % coinsurance for a one-month (30 day) supply of Tier 5 - Biotech and High Cost Brands - Brand drugs you get at an in-network preferred pharmacy.

• $ 0 for a three-month (90 day) supply of Tier 1 - Preferred Generics – Generic drugs you get at an in-network preferred pharmacy.

•  $ 30 for a three-month (90 day) supply of Tier 2 - Generic and Preferred Brand drugs

•   you get at an in-network preferred pharmacy.

• $ 75 for a three-month (90 day) supply of Tier 3 - Brands - Brand drugs you get at an in-network preferred pharmacy.

• 25 % coinsurance for a three-month (90 day) supply of Tier 4 - Injectibles - Generic and Brand drugs you get at an in-network preferred pharmacy.

• 25 % coinsurance for a three-month (90 day) supply of Tier 5 - Biotech and High Cost Brands - Brand drugs you get at an in-network preferred pharmacy.

• $ 0 for a three-month (90 day) supply of mail order Tier 1 - Preferred Generics -Generic drugs

• $ 20 for a three-month (90 day) supply of mail order Tier 2 - Generics and Preferred Brands - Generic and Preferred Brand drugs

• $ 50 for a three-month (90 day) supply of mail order Tier 3 - Brands – Brand drugs

• 25 % coinsurance for a three-month (90day) supply of mail order Tier 4 - Injectibles - Generic and Brand drugs

• 25 % coinsurance for a three-month (90 day) supply of mail order Tier 5 – Biotech and High Cost Brands - Brand drugs

The Member pays the co-payments and co-insurance as stated, until the total member and plan cost is $2,250.00.

After $2,250 in total costs, the member pays a 50% Coinsurance till the total co-payments and co-insurance is $ 3600 in yearly out of pocket expenses.

After your yearly out-of-pocket drug costs reach $3,600, you pay the greater of:

• $2 for Generic or Preferred Brand drugs that is  a multi-source drug and $5 for all other drugs, or

• 5% coinsurance.

Certain prescription drugs will have maximum quantity limits.  Contact plan for details.

Your provider must get prior authorization from Masterpiece Rx Choice prescription drugs.  Contact plan for details.

Covered Part D drugs are available at out-of-network pharmacies in special circumstances including illness while traveling outside of plan’s service area where there is no network pharmacy.

In addition to paying the co-payments/co-insurances listed below, you will be required to pay the difference between what we would pay for a prescription filled at an in-network pharmacy and what the out-of-network pharmacy charged for your prescriptions.

• $ 0 for a one-month (30 day) supply of Tier 1 - Preferred Generics – Generic drugs you get at an out-of-network pharmacy.

• $ 10 for a one-month (30 day) supply of Tier 2 - Generics and Preferred Brands - Generic and Preferred Brand drugs you get at an out-of-network pharmacy.

• $ 25 for a one-month (30 day) supply of Tier 3 - Brands - Brand drugs you get at an out-of-network pharmacy.

• 25 % coinsurance for a one-month (30 day) supply of Tier 4 - Injectibles - Generic and Brand drugs you get at an out-of-network pharmacy.

• 25 % coinsurance for a one-month (30 day) supply of Tier 5 - Biotech and High Cost Brands - Brand drugs you get at an out-of-network pharmacy.