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Drug Sponsor Name
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Universal Health Care Insurance Company, Inc.
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Drug Plan Name
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Any, Any, Any Platinum (PFFS) (H5820-013)
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Phone number
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Current Members/Prospective Members: 1-866-690-4842 TTY/TDD: 1-800-617-0177
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Web site
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www.univhc.com
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Total monthly premium
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$89.00
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Medicare Part D premium portion
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$14.80
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SPDAP monthly subsidy
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Up to $25 per month
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Monthly premium after subsidy
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$74.20
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Deductible
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$0
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1st tier copay
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$2.00
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2nd tier copay
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$7.00
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3rd tier copay
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$30.00
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4th tier copay and description (such as injectables, if applicable)
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$60.00
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5th tier copay – Specialty drugs
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33% coinsurance
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Benefits available in coverage gap
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None
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Mail order copays offered
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$4.00 for a 90-day supply of Preferred Generic drugs $14.00 for a 90-day supply of Non-Preferred Generic drugs $60.00 for a 90-day supply of Preferred Brand drugs $120.00 for a 90-day supply of Non-Preferred Brand drugs 33% coinsurance for a 90-day supply of Specialty drugs
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Maryland SPDAP Doughnut Hole Subsidy
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Not offered in this plan option
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