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Prescription Drug & Vaccine Coverage

Explore your plan's Part D Prescription Drug and vaccine benefits—including copays, drug tiers, and coverage phases.

Generations Advantage Prime (HMO-POS), Select (LPPO), Value Plus (HMO-POS), and Access (LPPO) plans have Part D Prescription Drug coverage built right into the plan. Your prescription coverage is included in your premium. 

Below you will find your plan's coverage information including drug costs and copays, drug tiers, and more.

In addition to prescription drug coverage, plan members also have vaccine coverage. This benefit gives members access to many routine vaccines with little or no out-of-pocket costs. 


Table of Contents:
  1. Part D Coverage Phases
  2. Prescription Drug Coverage by Plan
  3. Vaccine Coverage & Insulin Costs


Part D Prescription Drug Coverage Phases

(For All Plans with Part D)


NOTE: Select, Value Plus, and Access plans have a deductible for certain drug tiers that must be met before entering the Initial Coverage Phase.

See deductible details under your plan below.

*Different cost-sharing applies for members who receive "Extra Help" (Low-Income Subsidy (LIS/LICS))

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number one icon Deductible Phase

For plans with a deductible: The deductible applies to covered drugs in Tiers 3, 4, and 5.

You will pay the full cost for drugs in these tiers until the plan's deductible is met. Then you will enter the Initial Coverage Phase for drugs in these tiers.

For drugs in Tiers 1, 2, and 6, you start immediately in the Initial Coverage Phase.

number two icon Initial Coverage Phase*

You begin this phase when you fill your first prescription of the year and pay set copays or cost shares (noted under your plan below) for covered drugs until the total yearly drug costs (what you pay PLUS what the plan pays) reach $5,030.

Once the total reaches $5,030, you enter the Coverage Gap Phase.

number three icon Coverage Gap Phase*

In this phase, you pay 25% of the cost for generic drugs. For brand-name drugs, you receive a manufacturer’s discount, and you will pay 25% of the discounted cost plus a portion of the dispensing fee.**

  1. The total out-of-pocket drug costs YOU paid in the Deductible Phase PLUS
  2. The total out-of-pocket drug costs YOU paid in the Initial Coverage Phase PLUS
  3. The total out-of-pocket drug costs and dispensing fees YOU paid in the Coverage Gap Phase PLUS
  4. The total amount of the manufacturer’s discount you received in the Coverage Gap Phase.

Once the total reaches $8,000, you enter the Catastrophic Coverage Phase.

number four icon Catastrophic Coverage Phase*

Once you have moved into the Catastrophic Coverage phase, you pay $0 for covered drugs for the remainder of the year.

*Different cost-sharing applies for members who receive "Extra Help" (Low-Income Subsidy (LIS/LICS))

**Tier 6 copays in this phase are $0 for 30- and 90-day supplies at preferred retail and mail-order pharmacies, and 15% coinsurance at standard retail pharmacies. Additionally, plan costs from all phases ARE NOT COUNTED in the Coverage Gap Phase.


Prescription Drug Coverage by Plan

Expand All

Part D Prescription Drug coverage for Prime, Select, Value Plus, and Access plan members can be found below:

Your drug costs depend on what tier your drug is in, what "coverage phase" you are in, when you get the drug, and which pharmacy you use.


Prescription Deductible: $0 
Member Costs in Initial Coverage Phase

 

Tier 1: Preferred Generic

Tier 2: Generic

Tier 3: Preferred Brand

Tier 4:
Non-Preferred

Tier 5:
Specialty

 Tier 6:
Select Care Drug
Pharmacies with preferred cost sharing (including Hannaford pharmacies), 30-day supply* $0 $10 $40 $95 33% of cost  $0 
Pharmacies with preferred cost sharing (including Hannaford pharmacies), 90-day supply* $0 $30 $120 $285 Not Covered $0
Pharmacies with standard cost sharing, 30-day supply*  $4 $18 $47 $100 33% of cost $4
Pharmacies with standard cost sharing, 90-day supply* $12 $54 $141 $300 Not Covered $12
Mail order, 90-day supply*  $10 $45 $117.50 $250 Not Covered  $0 

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.

Your drug costs depend on what tier your drug is in, what "coverage phase" you are in, when you get the drug, and which pharmacy you use.


Prescription Deductible: $275 

The deductible applies to covered drugs in Tiers 3, 4, and 5. You will pay the full cost for drugs in these tiers until the $275 deductible is met. Then you will enter the Initial Coverage Phase for drugs in these tiers. For drugs in Tiers 1, 2, and 6, you start immediately in the Initial Coverage Phase.

Member Costs in Initial Coverage Phase

 

Tier 1: Preferred Generic

Tier 2: Generic

Tier 3: Preferred Brand

Tier 4:
Non-Preferred

Tier 5:
Specialty

 Tier 6:
Select Care Drug
Pharmacies with preferred cost sharing (including Hannaford pharmacies), 30-day supply* $0 $10 $40 $95 29% of cost  $0 
Pharmacies with preferred cost sharing (including Hannaford pharmacies), 90-day supply* $0 $30 $120 $285 Not Covered $0
Pharmacies with standard cost sharing, 30-day supply*  $4 $18 $47 $100 29% of cost $4
Pharmacies with standard cost sharing, 90-day supply* $12 $54 $141 $300 Not Covered $12
Mail order, 90-day supply*  $10 $45 $117.50 $250 Not Covered  $0 

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.

Your drug costs depend on what tier your drug is in, what "coverage phase" you are in, when you get the drug, and which pharmacy you use.


Prescription Deductible: $300 

The deductible applies to covered drugs in Tiers 3, 4, and 5. You will pay the full cost for drugs in these tiers until the $300 deductible is met. Then you will enter the Initial Coverage Phase for drugs in these tiers. For drugs in Tiers 1 and 2, you start immediately in the Initial Coverage Phase. The Value Plus plan does not include coverage for Tier 6 drugs.

Member Costs in Initial Coverage Phase

 

Tier 1: Preferred Generic

Tier 2: Generic

Tier 3: Preferred Brand

Tier 4:
Non-Preferred

Tier 5:
Specialty

 Tier 6:
Select Care Drug
Pharmacies with preferred cost sharing (including Hannaford pharmacies), 30-day supply* $0 $10 $40 $95 28% of cost  Not Covered
Pharmacies with preferred cost sharing (including Hannaford pharmacies), 90-day supply* $0 $30 $120 $285 Not Covered Not Covered
Pharmacies with standard cost sharing, 30-day supply*  $4 $18 $47 $100 28% of cost Not Covered
Pharmacies with standard cost sharing, 90-day supply* $12 $54 $141 $300 Not Covered Not Covered
Mail order, 90-day supply*  $10 $45 $117.50 $250 Not Covered Not Covered

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.

Your drug costs depend on what tier your drug is in, what "coverage phase" you are in, when you get the drug, and which pharmacy you use.


Prescription Deductible: $275 

The deductible applies to covered drugs in Tiers 3, 4, and 5. You will pay the full cost for drugs in these tiers until the $275 deductible is met. Then you will enter the Initial Coverage Phase for drugs in these tiers. For drugs in Tiers 1, 2, and 6, you start immediately in the Initial Coverage Phase.

Member Costs in Initial Coverage Phase

 

Tier 1: Preferred Generic

Tier 2: Generic

Tier 3: Preferred Brand

Tier 4:
Non-Preferred

Tier 5:
Specialty

 Tier 6:
Select Care Drug
Pharmacies with preferred cost sharing (including Hannaford pharmacies), 30-day supply* $0 $10 $40 $95 29% of cost  $0 
Pharmacies with preferred cost sharing (including Hannaford pharmacies), 90-day supply* $0 $30 $120 $285 Not Covered $0
Pharmacies with standard cost sharing, 30-day supply*  $4 $18 $47 $100 29% of cost $4
Pharmacies with standard cost sharing, 90-day supply* $12 $54 $141 $300 Not Covered $12
Mail order, 90-day supply*  $10 $45 $117.50 $250 Not Covered  $0 

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.

Part D Insulin Costs

Note: These prices apply to all plans with Part D coverage.

WHAT YOU PAY FOR PART D INSULIN—You won’t pay more than $35 for a one-month supply of each insulin product covered under your Part D Prescription Drug benefit, no matter what cost-sharing tier it’s on, even if you haven’t paid any applicable deductible.

  30-Day Supply
 60-Day Supply
 90-Day Supply
Insulin Copay $35 $70 $105

Part D Vaccine Coverage and Costs

Generations Advantage plans that include Part D Prescription Drug coverage now cover most Part D vaccines at no cost to you even if you haven’t paid any applicable Part D deductible your plan may have.


Out-of-Pocket Vaccine Cost Comparison

Several routine vaccines are available to all Generations Advantage plan members at little or no cost. Below is an overview of the cost and prescription requirements for several vaccines.

Vaccine cost and prescription requirements vary depending on where you receive the vaccine (at your doctor's office or at your local pharmacy). Please note that some vaccines are covered under your Medicare Part B (medical) benefit.

Vaccine

Name / Type

Your Cost at a
Doctor's Office*

Your Cost at a
Pharmacy
COVID-19
Medicare Part B		 All COVID-19 vaccines Medicare covers COVID-19 vaccines for members with no out-of-pocket costs. Visit your state's CDC website for vaccine locations.
Flu (Influenza)
Medicare Part B		 Quadrivalent
Trivalent
Intradermal
High Dose		  You pay $0 for this vaccine.
Pneumonia
Medicare Part B		 Pneumovax®
Prevnar 13®
Prevnar 20®		 You pay $0 for this vaccine.

You pay $0 for this vaccine.

NOTE: You must bring a prescription to the pharmacy
Shingles
Medicare Part D		  Shingrix®

You may have to pay full cost and submit to plan for 100% reimbursement for vaccine.

Shingrix® requires two shots and two payments/reimbursements.

You pay $0 for this vaccine.

NOTE: You must bring a prescription to the pharmacy
TDAP
Medicare Part D		  Adacel®
Boostrix®		  You may have to pay full cost and submit to plan for 100% reimbursement for vaccine.

You pay $0 for this vaccine.

NOTE: You must bring a prescription to the pharmacy

IMPORTANT: Before you get any tetanus vaccine, your doctor or pharmacist must call CVS Caremark for coverage determination.
Tetanus
Medicare Part D
 Preventative only.  You may have to pay full cost and submit to plan for 100% reimbursement for vaccine. overage determination is required for reimbursement. 

You pay $0  for this vaccine - coverage determination is required.

NOTE: You must bring a prescription to the pharmacy
Tetanus
Medicare Part B		 Treatment of wound.  You pay 20% of the cost of the vaccine.  Not available at a pharmacy.

*You will also pay any applicable office visit copay when you get your vaccine from your doctor. 

NOTE: Vaccine coverage is in accordance with the Inflation Reduction Act of 2022, as of January 1, 2023.

 

Have questions? We're here to help.

If you have questions about your plan, you can talk to a Member Service Representative by calling 1-866-544-7504.

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