Medicare Advantage Members
copay amounts – Gundersen health system Minnesota
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.
2024 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.
There is a deductible for Tiers 3, 4, and 5. Deductible is: Core D $300; Value D $250; Elite D $200.
| | Retail 30-day | Retail 60-day | Retail 90-day | Mail order 90-day |
|---|---|---|---|---|
| Tier 1 (Preferred Generic) | $5 | $10 | $15 | $12.50 |
| Tier 2 (Generic) | $15 | $30 | $45 | $38 |
| Tier 3 (Preferred Brand) | $47 | $94 | $141 | $117.50 |
| Tier 4 (Non-Preferred Drug) | $100 | $200 | $300 | $300 |
| Tier 5 (Specialty) | Core D = 28% Value D = 29% Elite D = 30% | N/A | N/A | N/A |
| Tier 6 (Vaccines) | $0 | N/A | N/A | N/A |
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 $5,030. 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 $8,000. Medicare sets this amount as well as the rules for what counts toward your OOP costs.
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 90-day | |
|---|---|---|---|---|
| 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
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 $4,660. 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 $7,400. 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 $7,400, you pay the greater of 5% of the drug cost or the copay. The copay is $4.15 for generic drugs or $10.35 for brand drugs.