Medicare Advantage Members
copay amounts – Gundersen health system
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.
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.
2023 Copay Amounts
Part D vaccines are covered at no cost to you. You won’t pay more than $35 for a one-month supply of covered insulin, no matter what cost-sharing tier it’s on.
|||Retail 30-day||Retail 60-Day||Retail 90-Day||Mail Order|
|Tier 1 (Preferred Generic)||$2||$4||$6||$5|
|Tier 2 (Generic)||$15||$30||$45||$38|
|Tier 3 (Preferred Brand)||$45||$90||$135||$113|
|Tier 4 (Non-Preferred Drug)||$100||$200||$300||$300|
|Tier 5 (Specialty)||33% of cost||N/A||N/A||N/A|
|Tier 6 (Vaccines)||$0||N/A||N/A||N/A|
Initial Coverage Gap begins at: $4,660 | Catastrophic Coverage begins at: $7,400
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.
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.
Senior Savings Program
Select insulins (insulins that are listed on our Drug Formulary) are available at a $35 copay per month at retail pharmacies, and $105 for 3 months through our mail-order pharmacy. Members will only pay this amount whether they are in the deductible, initial, or gap coverage phases.