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Your plan benefits coverage for what Medicare does not pay
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Plan Benefits for Level 1
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Monthly Premium
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Formulary
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Deductible
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Generic drug copay
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Preferred brand name drug copay
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Non-preferred brand name drug copay
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Gap Coverage for generic
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Medi-Pak Rx
Basic
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Medi-Pak Rx
Premier
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$31.30
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$83.50
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Standard
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Enhanced
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$250
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$0
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$6
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$6
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$39
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$39
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$69
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$69
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93% coinsurance
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$6 copay
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As of 9/1/2010, our network includes 735 participating pharmacies in Arkansas.
The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan. This is an advertisement; for more information, contact a benefits specialist.
S5795_Rx 2011 Website Submission CMS Approved 11082010
Web Page Last Updated: 8/30/2011
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