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Part D coverage details

For 2024 Medica AdvantageSM (PPO) members

About your Part D coverage

This plan provides four stages of coverage. You move from one stage to the next based on your prescription drug spending during the benefit year. See chapter 6 in your Evidence of Coverage (EOC) for the full description of your Part D benefits.

What you pay under Part D


  • What you pay for vaccines: Our plan covers most Part D vaccines at no cost to you, even if you haven’t paid your deductible. Call Member Services for more information.
  • What you pay for insulin: You won't pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it’s on, even if you haven’t paid your deductible.

Stage 1: Yearly deductible

Value H8889-010 NE/IA

  • Deductible = $0

Select H8889-015 NE/IA

  • Deductible = $0

Preferred H8889-011 NE/IA

  • Deductible = $0

Value H8889-014 ND/SD

  • Deductible = $325
  • Deductible does not apply
    to Tiers 1 & 2

Select H8889-012 ND/SD

  • Deductible = $175
  • Deductible does not apply
    to Tiers 1 & 2

Preferred H8889-013 ND/SD

  • Deductible = $0

 

Stage 2: Initial coverage

You need to first pay the full cost of your drugs until you reach the plan's deductible amount. Once you've met that deductible amount, you pay the following amounts for your covered prescription drugs from retail pharmacies.

Value H8889-010 NE/IA

  • Tier 1 - $0
  • Tier 2 - up to $14
  • Tier 3 - up to $47
  • Tier 4 - 50% of prescription cost
  • Tier 5 - 33% of prescription cost

Select H8889-015 NE/IA

  • Tier 1 - $0
  • Tier 2 - up to $12
  • Tier 3 - up to $47
  • Tier 4 - 50% of prescription cost
  • Tier 5 - 33% of prescription cost 

Preferred H8889-011 NE/IA

  • Tier 1 - $0
  • Tier 2 - up to $10
  • Tier 3 - up to $47
  • Tier 4 - 50% of prescription cost
  • Tier 5 - 33% of prescription cost

Value H8889-014 ND/SD

  • Tier 1 - $0
  • Tier 2 - up to $14
  • Tier 3 - up to $47
  • Tier 4 - 50% of prescription cost
  • Tier 5 - 28% of prescription cost

Select H8889-012 ND/SD

  • Tier 1 - $0
  • Tier 2 - up to $12
  • Tier 3 - up to $47
  • Tier 4 - 50% of prescription cost
  • Tier 5 - 30% of prescription cost

Preferred H8889-013 ND/SD

  • Tier 1 - $0
  • Tier 2 - up to $10
  • Tier 3 - up to $47
  • Tier 4 - 50% of prescription cost
  • Tier 5 - 33% of prescription cost

 

Stage 3: Initial coverage

After your total yearly combined drug costs reach $5,030, you pay 25% of generic prescription drugs and 25% of brand-name drugs until your total out-of-pocket expenses* reach $8,000 for the benefit year.

* Your total out-of-pocket expenses equals the total amount you paid in stage 2, plus the total amount paid in stage 3.

 

Stage 4: Catastrophic coverage

You enter the Catastrophic Coverage Stage when your out-of-pocket costs have reached the $8,000 limit for the calendar year. Once you are in the Catastrophic Coverage Stage, you will stay in this payment stage until the end of the calendar year.

  • During this payment state, the plan pays the full cost for your covered Part D drugs. You pay nothing.

These amounts apply for the remainder of the benefit year.

Note: The plan's formulary (the list of covered drugs) could change during the plan year. If we remove drugs from our formulary or add prior authorization, quantity limits, and/or step therapy restrictions on a drug, we’ll notify you of the change at least 60 days before it becomes effective, or when the you request a refill of the drug.


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Last Updated: December 2023