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-Day | Retail 60-Day | 90-Day | Mail Order 90-Day | |
|---|---|---|---|---|
| Yearly Deductible | $0 | $0 | $0 | $0 |
| Tier 1 (Preferred Generic) | $3 | $6 | $9 | $7 |
| Tier 2 (Generic) | $15 | $30 | $45 | $38 |
| Tier 3 (Preferred Brand) | $45 $35 for select insulins | $90 $70 for select insulins | $135 $105 for select insulins | $113 $87 for select insulins |
| Tier 4 (Non-preferred Drug) | 40% of cost | 40% of cost | 40% of cost | 40% of cost |
| Tier 5 (Specialty) | 30% of cost | N/A | N/A | N/A |
| Tier 6 (Vaccines) | $0 | $0 | $0 | $0 |
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.
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 $87 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.