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.
|Tier 1 (Preferred Generic)||$3||$6||$9||$7|
|Tier 2 (Generic)||$15||$30||$45||$38|
|Tier 3 (Preferred Brand)||$45|
$35 for select insulins
$70 for select insulins
$105 for select insulins
$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|
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 $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.