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
H6154-001
- Deductible = $545
- Deductible doesn't apply to Tier 1 and Tier2
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 preferred retail pharmacies.
H6154-001
- Tier 1 – $0
- Tier 2 – up to $14
- Tier 3 – up to $47
- Tier 4 – 47% of prescription cost
- Tier 5 – 25% of prescription cost
These are your coverage amounts for prescription drugs received from preferred retail pharmacies. Cost-sharing may vary when you receive prescription drugs from standard retail pharmacies, mail order, long-term care (LTC), or out-of-network pharmacies. You stay in the initial coverage stage until your total drug costs paid by you and Medicare for your prescription drugs reaches $5,030 for the benefit year.
Stage 3: Coverage gap
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 stages 1 – 3, plus the manufacturer discount 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