Part D Prescription Drug Coverage
Cost-sharing may change when you enter a new stage of the Part D benefit. For more information on the stages of the benefit, please contact the plan or view the Evidence of Coverage online at www.pthp.com.
Phase 1: Deductible Stage*: You must pay the full cost of your Tier 3, Tier 4, and Tier 5 drugs until you have paid the deductible. The amount of the deductible is listed in the chart below. For drugs in Tier 1, Tier 2, or covered insulins you do not pay a deductible and will receive coverage immediately at the copay amount listed below.
Phase 2: Initial Coverage Stage During this stage, the plan pays its share of the cost of your generic drugs and you pay your share of the cost. After you (or others on your behalf) have met your Tiers 3, 4, and 5 deductible, the plan pays its share of the costs of your Tiers 3, 4, and 5 drugs and you pay your share. You pay the following copays/coinsurance until your total yearly drug costs reach $4,660. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.
The below copays/coinsurance are for prescriptions purchased from network pharmacies. Costs will differ based on whether the prescriptions are filled at a preferred pharmacy, standard pharmacy, or mail order pharmacy. Refer to your pharmacy directory for information on which pharmacies are preferred or standard. Cost will also differ based on the number of days’ supply. Long-Term Care (LTC) pharmacies can fill up to a 31-day supply at the 30-day copays/ coinsurance listed below.
$125 Deductible for drugs in Tiers 3, 4, or 5; excluding covered insulins.
Initial Coverage Limit (up to $4,660 total drug cost):
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Preferred Pharmacy - Retail (up to a 90 day supply)
|
30 day
|
60 day
|
90 day
|
|
1 - Preferred Generic Drugs
|
$0 copay
|
$0 copay
|
$0 copay
|
|
2 - Generic Drugs
|
$15 copay
|
$30 copay
|
$45 copay
|
|
3 - Preferred Brand Drugs*
|
$42 copay
|
$84 copay
|
$126 copay
|
|
4 - Non-preferred Drugs*
|
$95 copay
|
$190 copay
|
$285 copay
|
|
5 - Specialty Drugs*
|
29% of the cost
|
Not available
|
Not available
|
|
Insulin Savings Program
|
$35 copay
|
$70 copay
|
$105 copay
|
|
Standard Pharmacy - Retail (up to a 90 day supply)
|
30 day
|
60 day
|
90 day
|
|
1 - Preferred Generic Drugs
|
$10 copay
|
$20 copay
|
$30 copay
|
|
2 - Generic Drugs
|
$18 copay
|
$36 copay
|
$54 copay
|
|
3 - Preferred Brand Drugs*
|
$47 copay
|
$94 copay
|
$141 copay
|
|
4 - Non-preferred Drugs*
|
$100 copay
|
$200 copay
|
$300 copay
|
|
5 - Specialty Drugs*
|
30% of the cost
|
Not available
|
Not available
|
|
Insulin Savings Program
|
$35 copay
|
$70 copay
|
$105 copay
|
|
Mail Order Pharmacy - Retail (up to a 90 day supply)
|
30 day
|
60 day
|
90 day
|
|
1 - Preferred Generic Drugs
|
$0 copay
|
$0 copay
|
$0 copay
|
|
2 - Generic Drugs
|
$15 copay
|
$30 copay
|
$45 copay
|
|
3 - Preferred Brand Drugs*
|
$45 copay
|
$90 copay
|
$125 copay
|
|
4 - Non-preferred Drugs*
|
$95 copay
|
$190 copay
|
$275 copay
|
|
5 - Specialty Drugs*
|
30% of the cost
|
Not available
|
Not available
|
|
Insulin Savings Program
|
$35 copay
|
$70 copay
|
$105 copay
|
Coverage Gap: The Coverage Gap begins after the total yearly drug cost reaches $4,660. If you reach the coverage gap, for tier 1, tier 2 or covered insulins, you will continue to pay the same copay. For other drugs in tier 3, drugs in tier 4 or tier 5 the plan pays 75% of the price for drugs and you pay the remaining 25% of the price. Not everyone will enter the Coverage Gap.
Catastrophic Coverage: After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,400, you pay the greater of:
- 5% of the cost, or
- $4.15 copay for generic (including brand drugs treated as generic) and an $10.35 copay for all other drugs.
If you reach the Catastrophic Coverage Stage, you will stay in this payment stage until the end of the calendar year.
This is not a complete description of benefits.
For coverage details and additional co-payments/co-insurance, please see the Summary of Benefits. Conditions and limitations may apply.
You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week; The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call 1-800-325-0778; or Your State Medicaid Office.
You must receive your care from a network provider.
In most cases, care you receive from an out-of-network provider (a provider who is not part of plan’s network) will not be covered. There are four exceptions:
- The plan covers emergency care or urgently needed services that you get from an out-of-network provider.
- If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider with our prior approval. In this situation with our approval, you will pay the same as you would pay if you got the care from a network provider.
- The plan covers kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area.
Our plan offers a point-of-service (POS) option for lab services, non-Medicare covered dental and vision services, hearing exams and hearing aids. For lab services, members may use the Medicare provider of their choice and services will be paid in-network. Molecular Diagnostics/Genetic testing requires prior authorization. For non-Medicare covered dental and vision services, members may use the provider of their choice and services will be reimbursed up to the plan annual maximum allowed. For hearing exams and/or hearing aids, you can use the provider of your choice, but you may have a higher out-of-pocket cost for hearing aids purchased from non-Amplifon providers. *The late enrollment penalty is an amount that is added to your Part D premium. You may owe a monthly late enrollment penalty if at any time after your initial enrollment period is over, there is a period of 63 or more days in a row when you don’t have Part D or other creditable prescription drug coverage. If you get "Extra Help" you do not pay a late enrollment penalty.
