Prescription Coverage
About Prescription Benefits
How Rx Plans Work
Pre-Coverage Gap (Initial Coverage Period)
Rx plans provide Tier 1 and Tier 2 prescription coverage immediately when your Health Alliance Medicare plan becomes active.
- The yearly deductible on Tier 3, Tier 4 and Tier 5 drugs varies by plan.
- Members pay copayments for 30-day supplies of Tier 1, Tier 2, Tier 3, Tier 4 and Tier 5 drugs that vary slightly based on which plan they choose.
- For Tier 5 drugs, known as Specialty drugs, members only pay 30 percent of the cost.
Learn more about our open formulary which allows some drugs not listed on our formulary to still be covered.
During the Coverage Gap
In 2012, the coverage gap begins when the amount you pay plus the amount Health Alliance Medicare pays for your prescription drugs reaches $2,930.
During this time:
- Rx plans do not provide coverage, which means you’ll be responsible for most of the cost for your medications until your total pharmacy spending reaches $4,700 (in 2012).
Post-Coverage Gap (Catastrophic Coverage)
In 2012, when your total pharmacy spending reaches $4,700 in a year, you leave the coverage gap and enter the catastrophic coverage period. During this period, prescription coverage means Health Alliance Medicare pays for most of your drug costs for the rest of the year, while you pay whichever is greater between:
- $2.60 for Tier 1 and Tier 2 drugs that are multi-source drugs and $6.50 for all other drugs, or
- 5 percent coinsurance
Learn more by visiting What’s the Coverage Gap?
How do I know when I’ve reached the coverage gap?
Health Alliance Medicare mails a monthly Part D Explanation of Benefits to Rx members that explains whether you are in the Initial Coverage Period, the Coverage Gap or the Catastrophic Coverage Period.
Important Notes about Coverage
Note:
If you don’t add pharmacy coverage when you become eligible for Medicare and don’t have coverage that is as good as or better than Part D prescription coverage (called creditable coverage), you will pay a penalty each month for as long as you have Part D coverage, if you choose to add it later. That penalty amount increases the longer you go without creditable or Part D prescription coverage.
Note:
Medicare beneficiaries may be enrolled in only one Part D prescription drug plan at a time. If a beneficiary is enrolled in a Medicare Advantage Part D prescription drug plan, the enrollee must receive his or her Medicare Part D benefit through that plan.
