About the Plan:
Our lower-premium plan covers a broad range of generic and brand name drugs. The plan’s five tiers of coverage give you cost sharing among generics and brand name drugs, as well as specialty drugs.
The plan has an annual deductible of $415.
For any preferred generic drug, you pay no more than $4 per fill. And for any Preferred Brand drug, no more than $40 per fill after deductible is met.
- Monthly premium: $59.10
- Annual deductible: $415
- Tier 1 - Preferred Generics: $4 copay per fill
- Tier 2 - Generics: $9 copay per fill
- Tier 3 - Preferred Brands: $40 copay per fill
- Tier 4 - Non Preferred Generic/ Non Preferred Brand: 45% coinsurance per fill
- Tier 5 - Specialty Generics or Brands 25% coinsurance per fill
Note: Per fill is equal to a 30 day supply
Prescription Drug Benefits
Drug Copay & Discounts
Prescription Drugs Benefits
|Annual Prescription Deductible
|Initial Coverage Stage
||Standard Network Pharmacy Cost Sharing (30 days)
||Preferred Mail Order Pharmacy (90 days)
|Tier 1: Preferred Generic Drugs
|Tier 2: Generic Drugs
|Tier 3: Preferred Brand Drugs
|Tier 4: Non-Preferred Generic/Brand Drugs
||45% of the cost
||45% of the cost
|Tier 5: Special Tier Drugs
||25% of the cost
||25% of the cost
|Coverage Gap Stage
Once a member's total drug costs have reached $3,820, they move to the Coverage Gap Stage.
- Member pays 37% of the price and the plan pays the remaining 63%. The amount paid by the plan (63%) does not count toward the members out-of-pocket costs. Only the amount paid by the member moves them through the coverage gap.
- Member pays 25% of the plan's negotiated price and a portion of the dispensing fee. The manufactureer provides a 70% discount excluding any dispensing fee. The amount paid by the member and the manufacturer discounted amount count towards the membe's out-of-pocket cost. The amount paid by the plan (5%) does not count towards the member's out-of-pocket cost.
Once the member's out-of-pocket costs reach $5,100, they move to the Catastrophic Coverage Stage.
|Catastrophic Coverage Stage
A member enters the Catastrophic Coverage Stage after $5,100 out-of-pocket costs are reached (excluding premiums). Through the end of the year, member pays the greater of: Generic drugs - $3.40 copay or a 5% coinsurance; Brand name drugs - $8.50 copay or a 5% coinsurance. On January 1 each year, the five drug payment stages start over.
- Members may use any pharmacy in the network but may not receive negotiated retail pharmacy pricing.
- Copays apply after deductible.
- You are not required to use Farm Bureau Essential Rx mail order to obtain a 90-day supply of your maintenance medication. New prescriptions for Essential Rx mail order should arrive within ten business days from the date the completed order is received and refill orders should arrive in about seven business days. Contact Farm Bureau Essential Rx anytime at (855) 540-4744 (TTY 711) 8am to 8pm, 7 days a week.
- Copays and coinsurance apply for all tiers during initial coverage phase and do not apply during coverage gap. Different copays or coinsurance apply during the catastrophic stage.
The monthly fee you pay to the plan for your health care. The amount shown does not include the Part B premium you already pay to the government. You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third party.
The following documents can help you get more information about this Medicare Part D plan, enroll in a plan and more. All documents are PDF (Portable Document Format) files. They can be viewed with Adobe Reader. If you don’t already have this viewer on your computer, download it free from the Adobe website.
|General Plan Information
||Enrollment Form (PDF)
Evidence of Coverage (PDF)
Summary of Benefits (PDF)
Annual Notice of Change (PDF)
Pharmacy Directory (PDF)
|Prescription Drug Coverage
||Comprehensive Formulary (PDF)
Prior Authorization Criteria (PDF)
Step Therapy Criteria (PDF)
Quantity Limits (PDF)
Quantity Limits (QL)
The plan will cover only a certain amount of this drug for a single copay or over a certain number of days. These limits may be in place to ensure safe and effective use of the drug. If your doctor prescribes more than this amount or thinks the limit is not correct for your situation, you and your doctor can ask the plan to cover the additional quantity.
Step Therapy (ST)
There may be effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try one or more of these lower-cost drugs before the plan will cover your drug. 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.
Prior Authorization (PA)
The plan requires you or your doctor to get prior authorization for certain drugs. This means the plan needs additional information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. If you do not get approval, the plan may not cover the drug.