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Part D coverage details 

For 2024 Medica Prime Solution Total with Rx (Cost) plan members

About your Part D coverage

This plan includes Part D coverage. You move from one coverage stage to the next based on your prescription drug spending during the calendar 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:

  • What you pay for vaccines: Your plan covers most Part D vaccines at no cost — even if you haven't paid your deductible. Call Member Services using the number on the back of your Medica member ID card 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 your plan — no matter what cost-sharing tier it's on — even if you haven't paid your deductible.

Stage 1: Yearly deductible

You pay the full cost of your Tier 3, Tier 4, and Tier 5 drugs until your $545 deductible is met. The deductible does not apply to your Tier 1 and Tier 2 drugs.

Stage 2: Initial coverage

Once you meet your $545 deductible, you pay the following amounts for your covered prescription drugs at a preferred network pharmacy. Refer to your Evidence of Coverage for details.

  • Tier 1 – $0
  • Tier 2 – up to $10
  • Tier 3 – up to $40
  • Tier 4 – 50% of prescription cost
  • Tier 5 – 25% of prescription cost

These are your preferred pharmacy copay and coinsurance amounts until the total amount paid by you and Medica for your prescription drugs reaches $5,030 for the calendar year.

Stage 3: Coverage gap

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

In stage 3 (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.

* Your total out-of-pocket expenses equals the total amount you paid in stages 1 - 3, plus the manufacturer discount paid in stage 3.
** The plan pays 5% of the drug cost.

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 stage, 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 let you know about the change at least 60 days before it becomes effective, or when you request a refill of the drug.


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Last Updated: December 2023