Pharmacy Benefit Copayment Overview 2023
Click for Prime (HMO-POS) and Focus DC (HMO SNP)
Part D Prescription Drug Benefits
Prime (HMO-POS) and Focus DC (HMO SNP) Plans
What you pay for your drugs depends on what "drug payment phase" you are in when you get the drug and which pharmacy you use.
Initial Coverage Phase*
You begin this phase when you fill your first prescription of the year and pay the following cost-shares for covered drugs until your total yearly drug costs (what you pay PLUS what the plan pays) reach $4,660.
| Your share of the cost when you get a one-month (30-day) supply (or less) of a covered Part D prescription drug from: | Your share of the cost when you get a long-term (90-day) supply of a covered Part D prescription drug from: | |||||
|---|---|---|---|---|---|---|
| Network pharmacy | The plan's mail order service | Network long-term care pharmacy (31 day supply) | Out-of-network pharmacy | Network pharmacy | The plan's mail order service | |
| Cost Share Tier 1 - preferred generic | ||||||
| Preferred network | $0 | N/A | N/A | N/A | $0 | N/A |
| Non-preferred network | $4 | $4 | $4 | $4 plus the cost difference between the Network and Non-Network Pharmacy | $12 | $10 |
| Cost Share Tier 2 - generic | ||||||
| Preferred network | $10 | N/A | N/A | N/A | $30 | N/A |
| Non-preferred network | $18 | $18 | $18 | $18 plus the cost difference between the Network and Non-Network Pharmacy | $54 | $45 |
| Cost Share Tier 3 - preferred brand | ||||||
| Preferred network | $40 | N/A | N/A | N/A | $120 | N/A |
| Non-preferred network | $47 | $47 | $47 | $47 plus the cost difference between the Network and Non-Network Pharmacy | $141 | $117.50 |
| Cost Share Tier 4 - non-preferred | ||||||
| Preferred network | $95 | N/A | N/A | N/A | $285 | N/A |
| Non-preferred network | $100 | $100 | $100 | $100 plus the cost difference between the Network and Non-Network Pharmacy | $300 | $250 |
| Cost Share Tier 5 - specialty tier | ||||||
| Preferred network | 33% | N/A | N/A | N/A | 33% | N/A |
| Non-preferred network | 33% | 33% | 33% | 33% plus the cost difference between the Network and Non-Network Pharmacy | 33% | 33% |
|
IMPORTANT NOTE ABOUT PRESCRIPTION PRICING: In some cases, the cost of a drug is lower than the copay amount of its Tier. In that situation, the plan would only charge the member the amount of the medication, not the full copay amount. |
||||||
Coverage Gap Stage*
After your total yearly drug costs (what you pay PLUS what the plan pays) reach $4,660, you will pay 25% of the price for brand name drugs (plus a portion of the dispensing fee) and pay 25% of the plan's costs for all generic drugs until your yearly out-of-pocket drug costs reach $7,400.
Focus DC only: You continue to pay the standard copayments for Tier 1 and Tier 2 drugs through the Coverage Gap stage.
Catastrophic Coverage Stage*
After your yearly out-of-pocket drug costs reach $7,400, you pay:
For Generics (including brand drugs treated as generic): The greater of $4.15 or a 5% coinsurance.
For all other drugs, the greater of $10.35 or a 5% coinsurance.
*Different cost-sharing applies for Members who receive "Extra Help" (Low-Income Subsidy (LIS/LICS))
Part D Prescription Drug Benefits
Select (LPPO) Plan
What you pay for your drugs depends on what "drug payment phase" you are in when you get the drug and which pharmacy you use.
Initial Coverage Phase*
You begin this phase when you fill your first prescription of the year and pay the following cost-shares for covered drugs until your total yearly drug costs (what you pay PLUS what the plan pays) reach $4,660.
| Your share of the cost when you get a one-month (30-day) supply (or less) of a covered Part D prescription drug from: | Your share of the cost when you get a long-term (90-day) supply of a covered Part D prescription drug from: | |||||
|---|---|---|---|---|---|---|
| Network pharmacy | The plan's mail order service | Network long-term care pharmacy (31 day supply) | Out-of-network pharmacy | Network pharmacy | The plan's mail order service | |
| Cost Share Tier 1 - preferred generic | ||||||
| Preferred network | $0 | N/A | N/A | N/A | $0 | N/A |
| Non-preferred network | $4 | $4 | $4 | $4 plus the cost difference between the Network and Non-Network Pharmacy | $12 | $10 |
| Cost Share Tier 2 - generic | ||||||
| Preferred network | $10 | N/A | N/A | N/A | $30 | N/A |
| Non-preferred network | $18 | $18 | $18 | $18 plus the cost difference between the Network and Non-Network Pharmacy | $54 | $45 |
| Cost Share Tier 3 - preferred brand | ||||||
| Preferred network | $40 | N/A | N/A | N/A | $120 | N/A |
| Non-preferred network | $47 | $47 | $47 | $47 plus the cost difference between the Network and Non-Network Pharmacy | $141 | $117.50 |
| Cost Share Tier 4 - non-preferred | ||||||
| Preferred network | $95 | N/A | N/A | N/A | $285 | N/A |
| Non-preferred network | $100 | $100 | $100 | $100 plus the cost difference between the Network and Non-Network Pharmacy | $300 | $250 |
| Cost Share Tier 5 - specialty tier | ||||||
| Preferred network | 33% | N/A | N/A | N/A | 33% | N/A |
| Non-preferred network | 28% | 28% | 28% | 28% plus the cost difference between the Network and Non-Network Pharmacy | 28% | 28% |
|
IMPORTANT NOTE ABOUT PRESCRIPTION PRICING: In some cases, the cost of a drug is lower than the copay amount of its Tier. In that situation, the plan would only charge the member the amount of the medication, not the full copay amount. Select (004 only) has a $275 deductible. For Tiers 1 and 2, you pay no deductible. For Tiers 3, 4, and 5 you pay 100% of the cost of the retail and mail order drugs until you spend $275.* For LTC, this is your share of the cost when you get a 31-day supply (or less) of a covered Part D prescription drug. |
||||||
Coverage Gap Stage*
After your total yearly drug costs (what you pay PLUS what the plan pays) reach $4,660, you will pay 25% of the price for brand name drugs (plus a portion of the dispensing fee) and pay 25% of the plan's costs for all generic drugs until your yearly out-of-pocket drug costs reach $7,400.
Catastrophic Coverage Stage*
After your yearly out-of-pocket drug costs reach $7,400, you pay:
For Generics (including brand drugs treated as generic): The greater of $4.15 or a 5% coinsurance.
For all other drugs, the greater of $10.35 or a 5% coinsurance.
*Different cost-sharing applies for Members who receive "Extra Help" (Low-Income Subsidy (LIS/LICS))
Part D Prescription Drug Benefits
Value Plus (HMO) Plan
What you pay for your drugs depends on what “drug payment phase” you are in when you get the drug and which pharmacy you use.
Deductible Phase
You begin this phase when you fill your first prescription of the year and pay your tier 1 and 2 cost-share and total cost of your tier 3, 4, and 5 drugs until you reach your $275 deductible.
Initial Coverage Phase
You begin this phase when you fill your first prescription after your deductible phase and pay the following cost-shares for covered drugs until your total yearly drug costs (what you pay PLUS what the plan pays) reach $4,660.
| Your share of the cost when you get a one-month (30-day) supply (or less) of a covered Part D prescription drug from: | Your share of the cost when you get a long-term (90-day) supply of a covered Part D prescription drug from: | |||||
|---|---|---|---|---|---|---|
| Network pharmacy | The plan's mail order service | Network long-term care pharmacy (31 day supply) | Out-of-network pharmacy | Network pharmacy | The plan's mail order service | |
| Cost Share Tier 1 - preferred generic | ||||||
| Preferred network | $0 | N/A | N/A | N/A | $0 | N/A |
| Non-preferred network | $4 | $4 | $4 | $4 plus the cost difference between the Network and Non-Network Pharmacy | $12 | $10 |
| Cost Share Tier 2 - generic | ||||||
| Preferred network | $10 | N/A | N/A | N/A | $30 | N/A |
| Non-preferred network | $18 | $18 | $18 | $18 plus the cost difference between the Network and Non-Network Pharmacy | $54 | $45 |
| Cost Share Tier 3 - preferred brand | ||||||
| Preferred network | $40 | N/A | N/A | N/A | $120 | N/A |
| Non-preferred network | $47 | $47 | $47 | $47 plus the cost difference between the Network and Non-Network Pharmacy | $141 | $117.50 |
| Cost Share Tier 4 - non-preferred | ||||||
| Preferred network | $95 | N/A | N/A | N/A | $285 | N/A |
| Non-preferred network | $100 | $100 | $100 | $100 plus the cost difference between the Network and Non-Network Pharmacy | $300 | $250 |
| Cost Share Tier 5 - specialty tier | ||||||
| Preferred network | 28% | N/A | N/A | N/A | 28% | N/A |
| Non-preferred network | 28% | 28% | 28% | 28% plus the cost difference between the Network and Non-Network Pharmacy | 28% | 28% |
| IMPORTANT NOTE ABOUT PRESCRIPTION PRICING: In some cases, the cost of a drug is lower than the copay amount of its Tier. In that situation, the plan would only charge the member the amount of the medication, not the full copay amount. | ||||||
Coverage Gap Stage*
After your total yearly drug costs (what you pay PLUS what the plan pays) reach $4,660, you will pay 25% of the price for brand name drugs (plus a portion of the dispensing fee) and pay 25% of the plan's costs for all generic drugs until your yearly out-of-pocket drug costs reach $7,400.
Catastrophic Coverage Stage*
After your yearly out-of-pocket drug costs reach $7,400, you pay:
For Generics (including brand drugs treated as generic): The greater of $4.15 or a 5% coinsurance.
For all other drugs, the greater of $10.35 or a 5% coinsurance.
*Different cost-sharing applies for Members who receive "Extra Help" (Low-Income Subsidy (LIS/LICS))
View Disclaimers