Changing the way you
receive healthcare

  • Part D Prescription Drug Coverage and Costs

    Members of PHP (HMO SNP) are subject to drug payment stages shown in the tables below.  PHP has no Part D premium in 2020. You must continue to pay your Medicare Part B premium. If you receive “Extra Help” (low income subsidy) from Medicare to help pay for your prescription drugs, read further below for cost sharing information specific to your level of “Extra Help.” Some people automatically qualify for “Extra Help” and don’t need to apply. Medicare mails a letter to people who automatically qualify for “Extra Help.” People with limited income and resources may qualify for “Extra Help.” You may be able to get “Extra Help” to pay for your prescription drug premiums and costs. To see if you qualify for getting “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. to 7 p.m., Monday through Friday. TTY users should call 1-800-325-0778; or
    • Your State Medicaid Office.
    2020 Cost-Sharing for Members Who Do Not Receive “Extra Help”

    Stage 1
    Yearly Deductible Stage

    Stage 2
    Initial Coverage Stage

    Stage 3
    Coverage Gap Stage

    Stage 4
    Catastrophic Coverage Stage

    You begin in this payment stage when you fill your first prescription of the year. During this stage you pay the full cost of your tier 1 through 4 drugs. You stay in this stage until you have paid $435 for your drugs ($435 is the amount of your deductible). During this stage, you pay coinsurance for covered drugs in tiers 1 through 4 as follows:
    • Tier 1 – 20%
    • Tier 2 – 15%
    • Tier 3 – 25%
    • Tier 4 – 25%
    You stay in this stage until your year-to-date “total drug costs” (your payments plus any Part D plan’s payments) total $4,020.
    During this stage, you pay 25% of the price for brand name drugs (plus a portion of the dispensing fee) and 25% of the price for generic drugs for your tier 1 through 4 drugs. You stay in this stage until your year-to-date “out-of-pocket costs” (your payments) reach a total of $6,350. This amount and rules for counting costs toward this amount have been set by Medicare. During this stage, you pay the greater of 5% coinsurance or $3.60 copayment for generic and multisource brand drugs, and $8.95 copayment for all other drugs for your tier 1 through 4 drugs for the rest of the calendar year (through December 31, 2020).
    For 2020, every drug in the formulary is in one of four cost-sharing tiers show below.
    Tier One-Month Supply Three-Month Supply
    Tier 1 (Generic Drugs) 20% of the Cost 20% of the Cost
    Tier 2 (Preferred Brand Drugs) 15% of the Cost 15% of the Cost
    Tier 3 (Non-Preferred Brand Drugs) 25% of the Cost 25% of the Cost
    Tier 4 (Specialty Drugs) 25% of the Cost 25% of the Cost
    Tier 5 (Select Care Drugs) No Cost No Cost
    If you get “Extra Help” (low income subsidy [LIS]) from Medicare, the cost-sharing tables below apply to you. If you qualify for LIS level 1, 2, or 3, the table immediately below applies. If you qualify for LIS level 4, the bottom table applies to you. The amount you pay for your prescription drugs depends on the level of LIS for which the Social Security Administration determines you qualify. PHP will tell you prior to beginning of the plan year or when you join the plan what your cost-sharing amounts are with LIS for the year. We will also tell you if your LIS is changing. 2020 Cost-Sharing for Members with LIS Levels 1, 2 or 3

    Stage 1
    Yearly Deductible Stage

    Stage 2 Initial Coverage Stage

    Stage 3
    Coverage Gap Stage

    Stage 4
    Catastrophic Coverage Stage

    This stage does not apply to you. There is no deductible for LIS levels 1, 2, or 3. You begin in this payment stage when you fill your first prescription of the year. During this stage, the plan pays its share of the cost of your drugs and you pay the following for tier 1 through 4 drugs:
    • Level 1: $3.60 copayment for generic and multisource brand drugs, and $8.95 copayment for all other drugs
    • Level 2: $1.30 copayment for generic and multisource brand drugs, and $3.90 copayment for all other drugs
    • Level 3: $0 copayment for all drugs
    You stay in this stage until your year-to-date “out-of-pocket costs” (the amount you and Medicare pay (as “Extra Help”)) reach a total of $6,350, and then you move to Stage 4.
    This stage does not apply to you. During this stage, you pay $0 copayment for all drugs for the rest of the calendar year (through December 31, 2020).
    2020 Cost-Sharing for Members with LIS Level 4

    Stage 1 Yearly Deductible Stage

    Stage 2 Initial Coverage Stage

    Stage 3 Coverage Gap Stage

    Stage 4 Catastrophic Coverage Stage

    You begin in this payment stage when you fill your first prescription of the year. During this stage you pay the full cost of your tier 1 through 4 drugs. You stay in this stage until you have paid $89 for your drugs ($89 is the amount of your deductible). During this stage, the plan pays its share of the cost of your drugs and you pay 15% coinsurance for covered drugs in tiers 1 through 4. You stay in this stage until your year-to-date “out-of-pocket costs” (the amount you and Medicare pay (as “Extra Help”)) reach a total of $6,350, and then you move to Stage 4. This stage does not apply to you. During this stage, you pay $3.60 copayment for generic and multisource brand drugs, and $8.95 copayment for all other drugs for tier 1 through 4 drugs the rest of the calendar year (through December 31, 2020).

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