2018 Creditable Coverage Information

Transcription

1 What is Creditable Coverage? 2018 Creditable Coverage Information Medicare beneficiaries have the opportunity to receive subsidized prescription drug coverage through the Medicare Part D program. Beneficiaries who choose not to sign up at the first opportunity may have to pay more if they wait to enter the program later after. Beneficiaries who have other sources of drug coverage - through a current or former employer or union, for example - may stay in that plan and choose not to enroll in the Medicare drug plan. If their other coverage is at least as good as the new Medicare drug benefit (and therefore considered "creditable coverage"), then the beneficiary can continue to get the high quality care they have now as well as avoid higher payments if they sign up later for the Medicare drug benefit. To determine if your prescription drug benefits are creditable, you should be able to answer the following questions: - What is your Rx copay structure? - What is your mail-order benefit? - Are your prescription drug benefits subject to a deductible? - If so, what is the annual single/family deductible? Prescription drug benefits are Creditable if they have one of the copay structures listed below AND a deductible less than or equal to the amount shown below. If "Not Creditable" is listed, then the copay structure is not considered Creditable coverage. EXAMPLE #1: Rx Copay Structure: $7/$30/50% Rx Subject to Deductible? Yes, Rx only Mail-Order Benefit: 2.5 copays Annual Deductible: $2,500/$5,000 Per the grid on the next page, $7/$30/50% is creditable with 2.5 copays when the single deductible is less than or equal to $2,250 and the family deductible is less than or equal to $4,500. Therefore, my prescription drug plan is not considered creditable. EXAMPLE #2: Rx Copay Structure: $7/$30/50% Rx Subject to Deductible? Yes, Health+Rx Mail-Order Benefit: 2.5 copays Annual Deductible: $1,500/$3,000 Per the grid on the next page, $7/$30/50% is creditable with 2.5 copays when the single deductible is less than or equal to $5,350 and the family deductible is less than or equal to $10,700. Therefore, my prescription drug plan is considered creditable. 1 of 8

2 2018 Creditable Coverage List for Rx Deductible Plans Mail-Order Benefit: 3 copays Mail-Order Benefit: 2.5 copays Mail-Order Benefit: 2 copays Generic Only Coverage $1 Generic only Not Creditable Not Creditable Not Creditable $100/$200 $3 Generic only Not Creditable Not Creditable Not Creditable Not Creditable $5 Generic only Not Creditable Not Creditable Not Creditable Not Creditable $7 Generic only Not Creditable Not Creditable Not Creditable Not Creditable $10 Generic only Not Creditable Not Creditable Not Creditable Not Creditable $15 Generic only Not Creditable Not Creditable Not Creditable Not Creditable Two-Tier Coverage (Generic& Brand) $0/$0 $3000/$6000 $3000/$6000 $3000/$6000 $3000/$6000 $0/$10 $2700/$5400 $2700/$5400 $2700/$5400 $2750/$5500 $0.50/$0.50 $200/$400 $250/$500 $300/$600 $450/$900 $1/$1 $2900/$5800 $2900/$5800 $2900/$5800 $2950/$5900 $1/$3 $2850/$5700 $2850/$5700 $2850/$5700 $2900/$5800 $1/$5 $2800/$5600 $2800/$5600 $2800/$5600 $2850/$5700 $2/$2 $2850/$5700 $2850/$5700 $2850/$5700 $2850/$5700 $3/$3 $2800/$5600 $2800/$5600 $2800/$5600 $2800/$5600 $3/$5 $2750/$5500 $2750/$5500 $2750/$5500 $2750/$5500 $3/$7 $2700/$5400 $2700/$5400 $2700/$5400 $2700/$5400 $3/$10 $2600/$5200 $2600/$5200 $2600/$5200 $2650/$5300 $4/$6 $2700/$5400 $2700/$5400 $2700/$5400 $2700/$5400 $5/$5 $2700/$5400 $2700/$5400 $2700/$5400 $2700/$5400 $5/$10 $2550/$5100 $2550/$5100 $2550/$5100 $2600/$5200 $5/$20 $2300/$4600 $2350/$4700 $2350/$4700 $2350/$4700 $7/$7 $2600/$5200 $2600/$5200 $2600/$5200 $2650/$5300 $7/$15 $2400/$4800 $2400/$4800 $2400/$4800 $2450/$4900 $7/$25 $2200/$4400 $2200/$4400 $2200/$4400 $2250/$4500 $9/$9 $2500/$5000 $2500/$5000 $2500/$5000 $2550/$5100 $9/$15 $2350/$4700 $2350/$4700 $2350/$4700 $2400/$4800 $10/$10 $2450/$4900 $2450/$4900 $2500/$5000 $2500/$5000 $10/$20 $2250/$4500 $2250/$4500 $2250/$4500 $2300/$4600 $15/$15 $2300/$4600 $2300/$4600 $2300/$4600 $2350/$ %/10% $2150/$4300 $2150/$4300 $2150/$4300 $2200/$ %/20% $1650/$3300 $1650/$3300 $1700/$3400 $1750/$ %/50% $200/$400 $250/$500 $300/$600 $450/$900 Three-Tier Coverage (Generic, Brand & Non-Formulary) 0%/0%/0% $3400/$6800 $3400/$6800 $3400/$6800 $3400/$6800 $0/$0/$0 $3400/$6800 $3400/$6800 $3400/$6800 $3400/$6800 $0/$7/$10 $3200/$6400 $3200/$6400 $3200/$6400 $3200/$6400 $0/$10/$20 $3100/$6200 $3100/$6200 $3100/$6200 $3100/$6200 $0/$30/$50 $2700/$5400 $2700/$5400 $2700/$5400 $2700/$5400 $0/$30/$100 $2650/$5300 $2650/$5300 $2650/$5300 $2700/$5400 $0/$50/$75 $2450/$4900 $2500/$5000 $2500/$5000 $2550/$5100 $0/$50/$100 $2450/$4900 $2450/$4900 $2450/$4900 $2500/$5000 $0/50%/50% $1150/$2300 $1150/$2300 $1200/$2400 $1300/$2600 $2/$25/50% $2400/$4800 $2400/$4800 $2400/$4800 $2450/$4900 $3/$10/$35 $2950/$5900 $2950/$5900 $2950/$5900 $3000/$ of 8

3 2018 Creditable Coverage List for Rx Deductible Plans Mail-Order Benefit: 3 copays Mail-Order Benefit: 2.5 copays Mail-Order Benefit: 2 copays $4/$8/$25 $3000/$6000 $3000/$6000 $3000/$6000 $3000/$6000 $4/$30/$50 $2550/$5100 $2550/$5100 $2550/$5100 $2600/$5200 $4/$35/$70 $2450/$4900 $2500/$5000 $2500/$5000 $2500/$5000 $4/$35/50% $2200/$4400 $2200/$4400 $2200/$4400 $2250/$4500 $4/$50/$80 $2300/$4600 $2350/$4700 $2350/$4700 $2400/$4800 $4/35%/50% $1350/$2700 $1400/$2800 $1450/$2900 $1500/$3000 $4/50%/50% $900/$1800 $950/$1900 $1000/$2000 $1100/$2200 $4/$100/$100 $1950/$3900 $1950/$3900 $2000/$4000 $2050/$4100 $5/$7/$10 $3050/$6100 $3050/$6100 $3050/$6100 $3050/$6100 $5/$7/$15 $3000/$6000 $3000/$6000 $3050/$6100 $3050/$6100 $5/$7/$20 $3000/$6000 $3000/$6000 $3000/$6000 $3050/$6100 $5/$10/$15 $2950/$5900 $2950/$5900 $2950/$5900 $2950/$5900 $5/$10/$25 $2950/$5900 $2950/$5900 $2950/$5900 $2950/$5900 $5/$10/$35 $2900/$5800 $2900/$5800 $2900/$5800 $2950/$5900 $5/$15/$25 $2800/$5600 $2800/$5600 $2850/$5700 $2850/$5700 $5/$15/$30 $2800/$5600 $2800/$5600 $2800/$5600 $2850/$5700 $5/$15/$35 $2800/$5600 $2800/$5600 $2800/$5600 $2850/$5700 $5/$20/$40 $2700/$5400 $2700/$5400 $2700/$5400 $2750/$5500 $5/$20/$45 $2700/$5400 $2700/$5400 $2700/$5400 $2750/$5500 $5/$20/$50 $2700/$5400 $2700/$5400 $2700/$5400 $2700/$5400 $5/$20/50% $2400/$4800 $2400/$4800 $2400/$4800 $2450/$4900 $5/$25/$50 $2600/$5200 $2600/$5200 $2600/$5200 $2650/$5300 $5/$30/$40 $2550/$5100 $2550/$5100 $2550/$5100 $2600/$5200 $5/$30/$45 $2550/$5100 $2550/$5100 $2550/$5100 $2600/$5200 $5/$30/$50 $2500/$5000 $2550/$5100 $2550/$5100 $2550/$5100 $5/$30/$75 $2500/$5000 $2500/$5000 $2500/$5000 $2550/$5100 $5/$30/$100 $2450/$4900 $2500/$5000 $2500/$5000 $2550/$5100 $5/$30/50% $2200/$4400 $2250/$4500 $2250/$4500 $2300/$4600 $5/$40/50% $2100/$4200 $2100/$4200 $2100/$4200 $2150/$4300 $5/$50/$75 $2300/$4600 $2300/$4600 $2350/$4700 $2350/$4700 $5/$50/$100 $2250/$4500 $2300/$4600 $2300/$4600 $2350/$4700 $5/20%/20% $1900/$3800 $1900/$3800 $1950/$3900 $2000/$4000 $5/30%/30% $1550/$3100 $1600/$3200 $1600/$3200 $1700/$3400 $5/50%/50% $900/$1800 $900/$1800 $950/$1900 $1100/$2200 $7/$15/$25 $2750/$5500 $2800/$5600 $2800/$5600 $2800/$5600 $7/$15/$30 $2750/$5500 $2750/$5500 $2800/$5600 $2800/$5600 $7/$15/$35 $2750/$5500 $2750/$5500 $2750/$5500 $2800/$5600 $7/$20/50% $2350/$4700 $2350/$4700 $2350/$4700 $2400/$4800 $7/$25/$40 $2550/$5100 $2600/$5200 $2600/$5200 $2600/$5200 $7/$30/$40 $2500/$5000 $2500/$5000 $2500/$5000 $2550/$5100 $7/$30/$50 $2500/$5000 $2500/$5000 $2500/$5000 $2550/$5100 $7/$30/$100 $2400/$4800 $2450/$4900 $2450/$4900 $2500/$5000 $7/$30/50% $2200/$4400 $2200/$4400 $2200/$4400 $2250/$4500 $7/$50/$75 $2250/$4500 $2250/$4500 $2300/$4600 $2350/$4700 $7/$50/$100 $2200/$4400 $2250/$4500 $2250/$4500 $2300/$4600 $10/$10/$30 $2850/$5700 $2850/$5700 $2850/$5700 $2850/$5700 $10/$15/$20 $2750/$5500 $2750/$5500 $2750/$5500 $2750/$5500 $10/$15/$25 $2750/$5500 $2750/$5500 $2750/$5500 $2750/$ of 8

4 2018 Creditable Coverage List for Rx Deductible Plans Mail-Order Benefit: 3 copays Mail-Order Benefit: 2.5 copays Mail-Order Benefit: 2 copays $10/$15/$35 $2700/$5400 $2700/$5400 $2750/$5500 $2750/$5500 $10/$20/$40 $2600/$5200 $2600/$5200 $2600/$5200 $2650/$5300 $10/$20/$45 $2600/$5200 $2600/$5200 $2600/$5200 $2650/$5300 $10/$20/50% $2300/$4600 $2300/$4600 $2300/$4600 $2350/$4700 $10/$25/$40 $2500/$5000 $2550/$5100 $2550/$5100 $2550/$5100 $10/$30/$50 $2450/$4900 $2450/$4900 $2450/$4900 $2500/$5000 $10/$30/$60 $2400/$4800 $2450/$4900 $2450/$4900 $2500/$5000 $10/$30/$75 $2400/$4800 $2400/$4800 $2450/$4900 $2450/$4900 $10/$30/$100 $2350/$4700 $2400/$4800 $2400/$4800 $2450/$4900 $10/$30/50% $2150/$4300 $2150/$4300 $2150/$4300 $2200/$4400 $10/$35/$45 $2400/$4800 $2400/$4800 $2400/$4800 $2450/$4900 $10/$35/$70 $2350/$4700 $2350/$4700 $2400/$4800 $2400/$4800 $10/$35/50% $2050/$4100 $2050/$4100 $2100/$4200 $2100/$4200 $10/$40/$100 $2250/$4500 $2250/$4500 $2300/$4600 $2350/$4700 $10/$50/$75 $2200/$4400 $2200/$4400 $2250/$4500 $2300/$4600 $10/$50/$100 $2150/$4300 $2200/$4400 $2200/$4400 $2250/$4500 $10/50%/50% $700/$1400 $750/$1500 $800/$1600 $950/$1900 $10/$75/$150 $1950/$3900 $1950/$3900 $2000/$4000 $2050/$4100 $15/$25/50% $2150/$4300 $2200/$4400 $2200/$4400 $2200/$4400 $15/$30/$50 $2400/$4800 $2400/$4800 $2400/$4800 $2450/$4900 $15/$30/$100 $2350/$4700 $2350/$4700 $2350/$4700 $2400/$4800 $15/$50/$75 $2150/$4300 $2150/$4300 $2200/$4400 $2250/$4500 $15/$50/$100 $2100/$4200 $2150/$4300 $2150/$4300 $2200/$4400 $15/$60/$100 $2050/$4100 $2050/$4100 $2100/$4200 $2150/$4300 $15/$50/50% $1850/$3700 $1900/$3800 $1900/$3800 $1950/$3900 $15/30%/50% $1300/$2600 $1350/$2700 $1350/$2700 $1450/$2900 $15/50%/50% $600/$1200 $650/$1300 $700/$1400 $850/$1700 $20/$30/50% $2050/$4100 $2050/$4100 $2100/$4200 $2100/$4200 $20/$40/$80 $2200/$4400 $2200/$4400 $2250/$4500 $2250/$4500 *No Annual or Lifetime Limits on Rx Coverage 4 of 8

5 2018 Creditable Coverage List for Health+Rx Deductible Plans Mail-Order Benefit: 3 copays Mail-Order Benefit: 2.5 copays Mail-Order Benefit: 2 copays Generic Only Coverage Generic Only Not Creditable Not Creditable Not Creditable $400/$800 Two-Tier Coverage (Generic& Brand) $0/$0 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $0/$10 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $0.50/$0.50 $800/$1600 $1000/$2000 $1200/$2400 $1800/$3600 $1/$1 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $1/$3 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $1/$5 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $2/$2 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $3/$3 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $3/$5 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $3/$7 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $3/$10 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $4/$6 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $5/$5 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $5/$10 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $5/$20 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $7/$7 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $7/$15 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $7/$25 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $9/$9 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $9/$15 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $10/$10 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $10/$20 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $15/$15 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$ %/10% $5500/$11000 $5500/$11000 $5500/$11000 $5500/$ %/20% $5500/$11000 $5500/$11000 $5500/$11000 $5500/$ of 8

6 2018 Creditable Coverage List for Health+Rx Deductible Plans Mail-Order Benefit: 3 copays Mail-Order Benefit: 2.5 copays Mail-Order Benefit: 2 copays 50%/50% $800/$1600 $1000/$2000 $1200/$2400 $1800/$3600 Three-Tier Coverage (Generic, Brand & Non-Formulary) 0%/0%/0% $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $0/$0/$0 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $0/$7/$10 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $0/$10/$20 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $0/$30/$50 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $0/$30/$100 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $0/$50/$75 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $0/$50/$100 $4600/$9200 $4600/$9200 $4800/$9600 $5200/$10400 $0/50%/50% $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $2/$25/50% $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $3/$10/$35 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $4/$8/$25 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $4/$30/$50 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $4/$35/$70 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $4/$35/50% $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $4/$50/$80 $5400/$10800 $5500/$11000 $5500/$11000 $5500/$11000 $4/35%/50% $3600/$7200 $3800/$7600 $4000/$8000 $4400/$8800 $4/50%/50% $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $4/$100/$100 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $5/$7/$10 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $5/$7/$15 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $5/$7/$20 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $5/$10/$15 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $5/$10/$25 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $5/$10/$35 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $5/$15/$25 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $5/$15/$30 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $5/$15/$35 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $5/$20/$40 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $5/$20/$45 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $5/$20/$50 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$ of 8

7 2018 Creditable Coverage List for Health+Rx Deductible Plans Mail-Order Benefit: 3 copays Mail-Order Benefit: 2.5 copays Mail-Order Benefit: 2 copays $5/$20/50% $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $5/$25/$50 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $5/$30/$40 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $5/$30/$45 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $5/$30/$50 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $5/$30/$75 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $5/$30/$100 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $5/$30/50% $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $5/$40/50% $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $5/$50/$75 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $5/$50/$100 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $5/20%/20% $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $5/30%/30% $3600/$7200 $3600/$7200 $3800/$7600 $4400/$8800 $5/50%/50% $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $7/$15/$25 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $7/$15/$30 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $7/$15/$35 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $7/$20/50% $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $7/$25/$40 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $7/$30/$40 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $7/$30/$50 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $7/$30/$100 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $7/$30/50% $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $7/$50/$75 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $7/$50/$100 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $10/$10/$30 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $10/$15/$20 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $10/$15/$25 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $10/$15/$35 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $10/$20/$40 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $10/$20/$45 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $10/$20/50% $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $10/$25/$40 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $10/$30/$50 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$ of 8

8 2018 Creditable Coverage List for Health+Rx Deductible Plans Mail-Order Benefit: 3 copays Mail-Order Benefit: 2.5 copays Mail-Order Benefit: 2 copays $10/$30/$60 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $10/$30/$75 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $10/$30/$100 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $10/$30/50% $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $10/$35/$45 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $10/$35/$70 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $10/$35/50% $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $10/$40/$100 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $10/$50/$75 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $10/$50/$100 $2800/$5600 $3000/$6000 $3200/$6400 $3800/$7600 $10/50%/50% $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $10/$75/$150 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $15/$25/50% $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $15/$30/$50 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $15/$30/$100 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $15/$50/$75 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $15/$50/$100 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $15/$60/$100 $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $15/$50/50% $5200/$10400 $5400/$10800 $5400/$10800 $5500/$11000 $15/30%/50% $2400/$4800 $2600/$5200 $2800/$5600 $3400/$6800 $15/50%/50% $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $20/$30/50% $5500/$11000 $5500/$11000 $5500/$11000 $5500/$11000 $20/$40/$80 $/$0 $/$0 $/$0 $/$0 *No Annual or Lifetime Limits on Rx Coverage 8 of 8