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Medicare Advantage Members

copay amounts – UW Health (SwedishAmerican)

The copay is the amount you pay when you get a prescription filled. A copay may be a flat dollar amount or a percentage of the total cost of a drug.

Drug Maintenance

Prescriptions are often sold in 30-day supplies. However, you can buy up to a 90-day supply on medications in tiers 1 through 4. Each 30-day supply will take one copay at a retail pharmacy. A 90-day supply equals three copays.

If you live in a long-term care facility, your copay is the same as in a retail pharmacy.

You can get prescriptions from an out-of-network pharmacy, but you may pay more.

Copay Amounts

30-dayRetail
60-Day
90-Day Mail Order
90-Day
 Yearly Deductible$150 Tiers 4-5$150 Tiers 4-5$150 Tiers 4-5$150 Tiers 4-5
 Tier 1 (Preferred Generic)$0$0$0$0
 Tier 2 (Generic)$12$24$36$30
 Tier 3 (Preferred Brand)$47
$35 for select insulins
$94
$70 for select insulins
$141
$105 for select insulins
$118
$87 for select insulins
 Tier 4 (Non-Preferred Drug)  30% of cost 30% of cost 30% of cost 30% of cost
 Tier 5 (Specialty) 30% of cost N/A N/AN/A 
 Tier 6 (Vaccines) $0$0$0$0
Initial Coverage Gap begins at: $4,430 | Catastrophic Coverage begins at: $7,050

Coverage Gap

Most Medicare drug plans have a coverage gap every year.

You enter the coverage gap once the total amount spent on Part D drugs reaches $4,430. This includes your payments plus plan payments. During this stage, you pay 25% of the price for drugs, plus a portion of the dispensing fee. You stay in this stage until your year-to-date out-of-pocket (OOP) costs (your payments) reach a total of $7,050. Medicare sets this amount as well as the rules for what counts toward your OOP costs.

Catastrophic Coverage

After your yearly out-of-pocket drug costs reach $7,050, you pay the greater of 5% of the drug cost or the copay. The copay is $3.95 for generic drugs or $9.85 for brand drugs.

Medicare Advantage Drug Information

Looking for information on your drug plan? Find answers to your questions and view the drug list.