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Stand-Alone Part D Prescription Drug Plan

This plan offers prescription drug coverage only. You can pair this plan with a Medicare Supplement plan for comprehensive coverage.
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Please Note:

The following rates are for 2012. Visit our 2011 website for rates and information for the remaining 2011 calendar year.

Services/Benefits
  Basic Prescription Drug Plan
Monthly Premium $46.60
Deductible $0 for Tier 1 and Tier 2; $200 for Tier 3, Tier 4 and Tier 5 drugs
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Pre-Coverage Gap Before your total yearly drug costs (this is both what you and your plan pay) reach $2,930.
One-month (30-day) supply of prescription drugs from an in-network retail pharmacy or through mail order In-Network:
  • $0 at Walmart and Sam’s Club for Tier 1 drugs; $5 at other network pharmacies
  • $30 for Tier 2 drugs
  • $44 for Tier 3 drugs
  • $95 for Tier 4 drugs
  • 27% coinsurance for Tier 5 Specialty drugs
  • Out-of-Network:
    Covered drugs are available in special circumstances, including illness and while traveling outside the plan’s service area where there is no network pharmacy. You may incur an additional cost.
Coverage Gap After your total yearly drug costs (this is both what you and your plan pay) reach $2,930.
  You pay 86% for all generic drugs and 100% of the discounted cost for all brand-name drugs until the total you’ve paid reaches $4,700.
Post-Coverage Gap After your yearly out-of-pocket drug costs reach $4,700, you pay the greater of:
One-month (30-day) supply
  • A $2.60 copay for Tier 1 and Tier 2 drugs and a $6.50 copay for all other drugs, or
  • 5% coinsurance
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All contents copyright (c) 2011 Health Alliance Medical Plans. All rights reserved. Every effort has been made to ensure that this information is accurate. It is not intended to replace the legal source. In case of any discrepancy between this information and the legal source, the legal source will govern in all cases.

Last Updated October 1, 2011

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CMS Approved 10/15/2011