NRECA's Copayment Plan
With the Copayment Plan, you pay a flat dollar amount for each prescription rather than a percentage of the cost. There are 4 levels, or “tiers,” of drugs, each with a different copayment amount. You pay only the copayment when you use drugs in Tier 1 (most generic drugs), even during the coverage gap, until you are eligible for catastrophic coverage. There is no deductible and no copayment for catastrophic coverage. The maximum you pay for 2012 is $4,700 in true out-of-pocket costs.
Step 1
For the first $2,930 in total drug costs, you pay only the copayment for each covered drug, depending on the type of drug you choose.
|
You Pay
|
Plan Pays
|
|
Pharmacy
|
Tier 1
|
Tier 2
|
Tier 3
|
Tier 4
|
| Retail up to 30 days |
$10 |
$35 |
$50 |
$75 |
Drug costs after copayments |
| Retail 31-90 days |
$30 |
$105 |
$150 |
Up to
30-day
supply
only
|
Drug costs after copayments |
| Mail order |
$20
for up to
90-day supply |
$70
for up to
90-day supply |
$100
for up to
90-day supply |
$75
for up to
30-day supply
|
Drug costs after copayments |
Step 2
Then you have a coverage gap, in which you pay a share of the cost until you reach $4,700, the maximum in true out-of-pocket costs or TrOOP.
|
You Pay
|
Plan Pays
|
|
Pharmacy
|
Tier 1
|
Tier 2
|
Tier 3
|
Tier 4
|
| Retail up to 30 days |
$10 |
- Brand-name drugs: you pay 50% and get 50% discount.
- Generic drugs: you pay 86%
|
Drug costs after copayments |
| Retail 31-90 days |
$30 |
- Brand-name drugs: you pay 50% and get 50% discount.
- Generic drugs: you pay 86%
|
Drug costs after copayments |
| Mail order |
$20 |
- Brand-name drugs: you pay 50% and get 50% discount.
- Generic drugs: you pay 86%
|
Drug costs after copayments |
Once the amount you paid and the manufacturer discounts you received equal the maximum in true out-of-pocket (TrOOP) costs, you are eligible for catastrophic coverage.
|
$4,700 |
|
Step 3
You pay nothing for covered drugs once you reach catastrophic coverage.
Tier 1—most generic drugs and some brand-name drugs
Tier 2—preferred brand-name drugs and some generic drugs
Tier 3—non-preferred brand-name drugs and some generic drugs
Tier 4—specialty drugs, both brand-name and generic specialty drugs