How Do Prescription Drug Plans Work?
Here is important information you need to know about owning a prescription drug plan:
- Annual Deductible — There is a deductible you must pay for a Part D plan. Your deductible may be different, or waived entirely, but the max amount you can be charged is $415 in 2019. You will pay a discounted price for your medications until you have satisfied the deductible. After that, you begin initial coverage.
- Initial Coverage — During initial coverage, you pay a copay for your medications based on your plan’s formulary. Each prescription drug plan separates its medications into tiers. Each tier has a copy amount for which you are responsible. It is typically separated by generic drugs, preferred name brands, even more specialized medications, and etc. In 2019, the initial coverage cap is $3,820. After you and the insurance company together have paid this amount, then you enter the coverage gap.
- The Coverage Gap – During the coverage gap, you will still generally have significant discounts for generic medications. Typically, you will pay 25% for name brand medications and 37% for generics. Your gap spending will continue until you have paid $5100 out of your own pocket in 2019.
- Catastrophic Coverage – If you should spend past the coverage gap, your plan will begin to pay 95% of the costs of your formulary medications for the rest of the year.
How would I enroll?
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General disclaimers
We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area.
Please contact Medicare.gov or 1–800–MEDICARE (TTY users should call 1-877-486-2048) 24 hours a day/7 days a week or your local State Health Insurance Program to get information on all of your options.
Agency represents Medicare HMO, PPO, and PFFS organizations and stand-alone PDP prescription drug plans that have a Medicare contract. Enrollment depends on the plan’s contract renewal.
The plans we represent do not discriminate on the basis of race, color, national origin, age, disability, or sex. To learn more about a plan’s nondiscrimination policy, please click any of the Nondiscrimination links above in the Health plan disclaimers section.
This information is not a complete description of benefits. Call 1-956-342-9469 (TTY: 711) for more information.
Medicare beneficiaries may also enroll in the plan through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov.
For a complete list of available plans please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
Every year, Medicare evaluates plans based on a 5-star rating system.
Out-of-network/non-contracted providers are under no obligation to treat Plan members, except in emergency situations.
Please call the Plan’s customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.
Total annual cost is calculated by adding up the total annual cost of any monthly premiums, applicable plan deductible(s) and estimates for all co-pay and co-insurance amounts that will be due for the medications and health benefits used throughout the year.
Costs for medications and health benefits vary across pharmacies and health systems, so the costs provided are only estimates. Actual costs could vary.
For plans with Part D Coverage: You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for 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 or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 8 a.m. and 7 p.m., Monday through Friday.
TTY users should call, 1-800-325-0778 or consult www.socialsecurity.gov; or your Medicaid Office.
You must have both Part A and B to enroll in a Medicare Advantage plan. Members may enroll in the plan only during specific times of the year. Contact the plan for more information.
The purpose of this communication is the solicitation of insurance. Contact will be made by an insurance agent/producer or insurance company.
To send a complaint to a Medicare Health Plan, call the Plan or the number on your member ID card. To send a complaint to Medicare, call 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week). If your complaint involves a broker or agent, be sure to include the name of the person when filing your grievance.