2015 Medica Prime Solution Value with Part D Option 1 (Cost) Drug Coverage Details



Below is the Formulary, or drug list, for Medica Prime Solution Value with Part D Option 1 (Cost) from Medica Insurance Company This formulary is a list of prescription medications that are covered under Medica Insurance Company's 2015 Medicare Advantage Plan. The Medica Prime Solution Value with Part D Option 1 (Cost) plan has a $320 drug deductible. This deductible is the amount of expenses that must be paid out of pocket before the Initial Coverage period begins. However some drugs do not require that the deductible is met before you receive coverage. You can see if the deductible is required below in the "Does the Deductible Apply" column. The Initial Coverage Limit (ICL) for this plan is $2960. The Initial Coverage Period is the period after the Deductible has been met but before the Coverage Gap phase. Once you and your plan provider have spent $2960 on covered drugs. (combined amount plus your deductible) You will enter the coverage gap. (AKA "donut hole") Once you reach the coverage gap you will be required to pay 45% of the plan's cost for covered brand-name prescription drugs unless your plan offers additional coverage. You can see if this plan offers coverage in the "donut hole" be clicking the "Coverage Gap" link on the left above the chart. In 2015 if you have spent $4700 in expenditures you enter the Catastrophic Phase. During the Catastrophic Period you will begin to receive significant coverage. Medica Prime Solution Value with Part D Option 1 (Cost) will begin paying approximately 95% of your covered medication expenses. You can see if this plan covers your drugs in the Catastrophic Phase by clicking the "Catastrophic" link on the left above the chart.





Plan Name:
Medica Prime Solution Value with Part D Option 1 (Cost)
Plan ID:
H2450-022
Provider: Medica Insurance Company
Plan Year:2015
Premium:$23.80
Deductible:$320
Initial Coverage Limit:$2960
Coverage Area:Minnesota






Current Table info:


Coverage level : Initial Coverage
Days Supply : 30 Days
Drugs Starting With Letter: U



Change Table Options:


Drugs Starting Letter:
A  B  C  D  E  F  G  H  I  J  K  L  M 
N  O  P  Q  R  S  T  U  V  W  X  Y  Z 

Coverage Level:
Pre-deductible,Initial Coverage
Coverage Gap, Catastrophic

Drug Days Pricing:
30 Day Supply, 60 Day Supply, 90 Day Supply

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(Click the Drug Name to Compare every Plans Price)

Drug Name Drug Strength Units in Package Tier Level Amount Limit Days Limit Prior Authorization Y/N Step Therapy Y/N Does the Deduct Apply Cost Prefered Max Cost Pref Cost Non Pref Max Cost Non Pref Cost Amt Mail Max Cost Mail
U-cort 10mg/g 1 Tube In 1 Carton > 28.35 G In 1 Tube
2
N N N N Y 25%None25%NoneNANone
Uceris 9mg 30 Tablet, Extended Release In 1 Bottle
5
N N N Y Y 25%None25%NoneNANone
Ulesfia 50mg/g 2 Bottle, Plastic In 1 Carton > 227 G In 1 Bottle, Plastic
4
N N N N Y 25%None25%NoneNANone
Uloric 80mg 30 Tablet In 1 Bottle
3
30 30 N Y Y 25%None25%NoneNANone
Uloric 40mg 30 Tablet In 1 Bottle
3
30 30 N Y Y 25%None25%NoneNANone
Ultracet 325; 37.5mg/1; mg 10 Blister Pack In 1 Box, Unit-dose > 10 Tablet, Coated In 1 Blister Pack
4
240 30 N N Y 25%None25%NoneNANone
Ultram 50mg 100 Tablet, Coated In 1 Bottle
4
240 30 N N Y 25%None25%NoneNANone
Ultram Er 100mg 30 Tablet, Extended Release In 1 Bottle, Plastic
4
90 30 N N Y 25%None25%NoneNANone
Ultram Er 200mg 30 Tablet, Extended Release In 1 Bottle, Plastic
4
30 30 N N Y 25%None25%NoneNANone
Ultram Er 300mg 30 Tablet, Extended Release In 1 Bottle, Plastic
4
30 30 N N Y 25%None25%NoneNANone
Ultravate .5mg/g 1 Tube In 1 Carton > 50 G In 1 Tube
4
N N N N Y 25%None25%NoneNANone
Ultravate .5mg/g 1 Tube In 1 Carton > 50 G In 1 Tube
4
N N N N Y 25%None25%NoneNANone
Ultresa 27600; 13800; 27600[USP'U]/1; [USP'U]/1; [USP'U] 1 Bottle In 1 Carton > 100 Capsule, Delayed Release In 1 Bottle
4
N N N N Y 25%None25%NoneNANone
Ultresa 46000; 23000; 46000[USP'U]/1; [USP'U]/1; [USP'U] 1 Bottle In 1 Carton > 100 Capsule, Delayed Release In 1 Bottle
4
N N N N Y 25%None25%NoneNANone
Ultresa 41400; 20700; 41400[USP'U]/1; [USP'U]/1; [USP'U] 1 Bottle In 1 Carton > 100 Capsule, Delayed Release In 1 Bottle
4
N N N N Y 25%None25%NoneNANone
Unasyn 2; 1g/1; g 10 Vial In 1 Carton
4
N N N N Y 25%None25%NoneNANone
Unasyn 100; 50mg/mL; mg/mL 92 Ml In 1 Vial, Pharmacy Bulk Package
4
N N N N Y 25%None25%NoneNANone
Uniretic 12.5; 15mg/1; mg 100 Tablet, Film Coated In 1 Bottle
4
N N N N Y 25%None25%NoneNANone
Unithroid .025mg 100 Tablet In 1 Bottle, Plastic
4
N N N N Y 25%None25%NoneNANone
Unithroid .05mg 100 Tablet In 1 Bottle, Plastic
4
N N N N Y 25%None25%NoneNANone
Unithroid .075mg 100 Tablet In 1 Bottle, Plastic
4
N N N N Y 25%None25%NoneNANone
Unithroid .088mg 100 Tablet In 1 Bottle, Plastic
4
N N N N Y 25%None25%NoneNANone
Unithroid .1mg 100 Tablet In 1 Bottle, Plastic
4
N N N N Y 25%None25%NoneNANone
Unithroid .112mg 100 Tablet In 1 Bottle, Plastic
4
N N N N Y 25%None25%NoneNANone
Unithroid .125mg 100 Tablet In 1 Bottle, Plastic
4
N N N N Y 25%None25%NoneNANone
Unithroid .15mg 100 Tablet In 1 Bottle, Plastic
4
N N N N Y 25%None25%NoneNANone
Unithroid .175mg 100 Tablet In 1 Bottle, Plastic
4
N N N N Y 25%None25%NoneNANone
Unithroid .2mg 100 Tablet In 1 Bottle, Plastic
4
N N N N Y 25%None25%NoneNANone
Unithroid .3mg 100 Tablet In 1 Bottle, Plastic
4
N N N N Y 25%None25%NoneNANone
Univasc 7.5mg 100 Tablet, Film Coated In 1 Bottle
4
N N N N Y 25%None25%NoneNANone
Univasc 15mg 100 Tablet, Film Coated In 1 Bottle
4
N N N N Y 25%None25%NoneNANone
Urecholine 10mg 100 Tablet In 1 Bottle
4
N N N N Y 25%None25%NoneNANone
Urecholine 25mg 100 Tablet In 1 Bottle
4
N N N N Y 25%None25%NoneNANone
Urecholine 50mg 100 Tablet In 1 Bottle
4
N N N N Y 25%None25%NoneNANone
Urecholine 5mg 100 Tablet In 1 Bottle
4
N N N N Y 25%None25%NoneNANone
Urocit-k 5meq 100 Tablet, Extended Release In 1 Bottle
4
N N N N Y 25%None25%NoneNANone
Urocit-k 10meq 100 Tablet, Extended Release In 1 Bottle
4
N N N N Y 25%None25%NoneNANone
Urocit-k 15meq 100 Tablet, Extended Release In 1 Bottle
4
N N N N Y 25%None25%NoneNANone
Uroxatral 10mg 100 Tablet, Extended Release In 1 Bottle
4
N N N N Y 25%None25%NoneNANone
Urso 250 250mg 100 Tablet, Film Coated In 1 Bottle
4
N N N N Y 25%None25%NoneNANone
Urso Forte 500mg 100 Tablet, Film Coated In 1 Bottle
4
N N N N Y 25%None25%NoneNANone
Ursodiol 300mg 100 Blister Pack In 1 Box, Unit-dose
2
N N N N Y 25%None25%NoneNANone
Ursodiol 250mg 100 Tablet In 1 Bottle
2
N N N N Y 25%None25%NoneNANone
Ursodiol 500mg 100 Tablet In 1 Bottle
2
N N N N Y 25%None25%NoneNANone
Uvadex 20ug/mL 12 Vial, Glass In 1 Carton > 10 Ml In 1 Vial, Glass
4
N N N N Y 25%None25%NoneNANone



Medicare Help's

Additional Notes:



Coverage Levels for H2450-022

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1.Pre-Deductable: Before you reach the plans deductible of $320. Some plans offer select Pre-deductible drug Coverage
2.Initial Coverage: (ICL) After you reach the plans deductible but before the Initial Coverage limit of $2960
3.Coverage Gap: (AKA Donut Hole) After you reach the plans ICL but before the Catastrophic of $4700 in 2015.
4.Catastrophic: Anything over $4700 you will receive a significant increase in coverage.

Definitions:

Premium: A monthly flat fee that varies by plan.
Deductible: The amount you must pay each year for your prescriptions before your plan begins to pay its share of your covered drugs. The max in 2015 is $320. Some plans have a $0 Deductible.
Tier Level: Medicare drug plans place drugs into different "tiers" on their formularies. Drugs in each tier have a different cost. A drug in a lower tier will generally cost you less.
Quantity Limit Amount/Days: Certain drugs have a Quantity Limit. That means the plan will only cover the drug up to a designated quantity or amount. If your prescribing doctor feels it is necessary to exceed the set limit, he or she must get prior approval before the higher quantity will be covered.
Prior Authorization: Certain Drugs require you or your doctor to get prior authorization in order to be covered. Usually just an additional form. If you dont get approval, the plan may not cover the drug.
Does the Deduct Apply: Some drugs do not require that the deductible is met before you receive coverage.
Step Therapy: Means you must first try one drug to treat your medical condition before the plan will cover another drug for the same condition. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.
Cost Prefered: Your Cost for the Drug at the Providers In Network Prefered Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Non Pref: Your Cost for the Prescription Drug at a Non-Prefered Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Mail: Your Cost for Prescription Drugs through a Mail Order Pharmacy. As a Percent of the total drug cost or a flat rate.


What if a drug I need is not listed?

Please check the formulary for different brand and generic names. If you still cannot locate your drugs, your plan may not offer coverage. Talk to your doctor first about changing your prescription to a drug on your plans formulary. If this is not an option, you can request an exception to have the plan review its coverage decision based on your individual circumstances.

Source:CMS Formulary Data Oct. 2014
Source:NDC Directory by FDA.gov

**We make every attempt to keep our information accurate. But please check with the plan providers to verify all information.

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