Medicare Advantage Members

copay amounts – UW Health – Illinois

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.

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-dayRetail 60-DayRetail 90-Day Mail Order
 Tier 1 (Preferred Generic) $0 $0 $0 $0
 Tier 2 (Generic) $12$24 $36 $30 
 Tier 3 (Preferred Brand)$47 $94 $141 $118 
 Tier 4 (Non-Preferred Drug)   $100 $200 $300 $300
 Tier 5 (Specialty) 33% of costN/A N/A N/A
Tier 6 (Vaccines)$0N/AN/AN/A

Initial Coverage Gap begins at: $4,660 | Catastrophic Coverage begins at: $7,400

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.