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Part D coverage details

For 2023 Medica Advantage Solution (PPO) members

About

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.

Important message about your Part D coverage


Important Message About 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.

Important Message About 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 Stage

Deductible: $0

Stage 2: Initial Coverage Stage

Your share of the cost will vary depending on the drug and where you fill your prescription.

Your plan has 5 cost-sharing tiers. The amounts listed below are what you will pay for a 30 day fill at preferred pharmacies.

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

These are your copay and coverage amounts until the total amount paid by you and Medica for your prescription drugs reaches $4,660 for the benefit year.

Stage 3: Coverage Gap Stage

After your total yearly combined drug costs reach $4,660, you pay 25% of generic prescription drugs and 25% of brand-name drugs plus a portion of the dispensing fee until your total out-of-pocket expenses reach $7,400 for the benefit year.

In Stage 3 coverage (called the coverage gap), you get a manufacturer-paid 70% discount on covered brand-name drugs. A total of 95%* of the drug cost — including the part covered by the manufacturer discount and your out-of-pocket cost — counts toward your drug costs and helps you move through the coverage gap.

Additional gap coverage

You have additional gap coverage for select insulins. You continue to pay a $35 copayment for a one-month supply of select insulins through the coverage gap stage.

* 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 Stage

After you've reached $7,400 in drug costs, you pay the greater amount of:

  • $4.15 for generic drugs (including brand-name drugs treated as generic) and $10.35 for all other drugs, or
  • 5% coinsurance

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 let you know about 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: November 2022