Highlights for PDP Plans 2013
Pharma Plus
PDP
• $14.80 Monthly Plan Premium
• 25% coinsurance on all medication up to a limit of $2,970
Click one of the following links to download the document in PDF format:
Summary of Benefits
S5840_FP_13_1061_01_I F&U
Evidence of Coverage
S5840_FP_13_1127_01_I F&U
Enrollment Form
S5840_FP_13_1070_01_I CMS APPROVED 09/13/2012
Pharma Premium
PDP
• $78.20 Monthly Plan Premium
• $4 copay for Generic Drugs, Unlimited
• $20 copay for Preferred Brand Name Drugs
• $45 copay for Non-Preferred Brand Name Drugs
Click one of the following links to download the document in PDF format:
Summary of Benefits
S5840_FP_13_1061_01_I F&U
Evidence of Coverage
S5840_FP_13_1127_02_I F&U
Enrollment Form
S5840_FP_13_1070_01_I CMS APPROVED 09/13/2012
Employer Group Health Plans
PDP Gobierno
• $78.20 Monthly Plan Premium
• $4 copay for Generic Drugs, Unlimited
• $20 copay for Preferred Brand Name Drugs
• $45 copay for Non-Preferred Brand Name Drugs
Click one of the following links to the document in PDF format:
Summary of Benefits
S5840_FP_GOB_13_1061_01_I FYI
Evidence of Coverage
S5840_FP_GOB_13_1127_01_I FYI
Enrollment Form
S5840_FP_GOB_13_1070_01_I FYI