Understanding Your Medicare Drug Coverage
Medicare Part D, or prescription drug coverage, is complicated. At Network Health, we want to be as clear as possible. Let us help you understand the process.
This year, our Network PlatinumPlus Pharmacy (PPO) and Network PlatinumSelect (PPO) plans include a pharmacy deductible of $200 for some drugs. By adding a deductible, Network Health was able to maintain low copayments for drugs in tiers 1 and 2 and reduce the cost of tier five drugs significantly.
WHAT IS A DRUG TIER?
It’s a cost category a drug belongs to. The tier a drug is on determines what you pay for the drug, and usually the higher the tier the more you pay. You can find out what tier a drug is on by looking it up in our drug list, called the formulary.
WHAT IS A DRUG DEDUCTIBLE?
A drug deductible is a common component of many Part D plans because it helps offset the rising costs of pharmacy plans. The deductible is the amount you pay before your plan starts paying for any expenses. The good news is that our Medicare Part D deductible only applies to drugs in tiers 3, 4 and 5.
WHAT IS A COPAYMENT?
A copayment is the set fee you pay for a prescription drug. Your copayment will vary based on
the drug tier and whether you are in initial coverage, the coverage gap or the catastrophic coverage period.
WHAT IS THE COVERAGE GAP?
When your total drug costs reach $3,310, you enter the Medicare Part D coverage gap. During the coverage gap, you pay 58 percent, and Network Health pays 42 percent for generic drugs. For brand name drugs, you pay 45 percent, and Network Health pays 5 percent and the drug company pays 50 percent.
WHAT IS CATASTROPHIC COVERAGE?
When your prescription payments reach $4,850, you enter the catastrophic coverage phase. In catastrophic coverage, you pay the greater of $2.95 or five percent of the cost of generic drugs. For brand name drugs, you pay the greater of $7.40 or five percent of the cost.
Remember, your drug deductible and copayments count toward your drug costs for entering the catastrophic coverage phase.
If you’re concerned about paying for your prescriptions, there may be ways to lower drug costs. First, ask your doctor if there is a generic drug equivalent for brand name drugs. Generic drugs are more likely to be categorized in tier 1 and tier 2, avoiding the Medicare Part D deductible. You can also save costs by filling your prescriptions at a preferred pharmacy. Preferred pharmacies offer lower copayments than standard pharmacies.
If you would like assistance with your Medicare Part D drug coverage, call your Network Health Health Care Concierge or customer service at 800-378-5234 (TTY users call 800-947-3529) Monday through Friday, 8 a.m. – 8 p.m. You can also learn more at NetworkHealthMedicare.com.
Network Health Medicare Advantage plans include MSA and PPO plans with a Medicare contract. NetworkCares is a PPO SNP plan with a Medicare contract and a contract with the Forward Health Wisconsin Medicaid program. Enrollment in Network Health Medicare Advantage Plans depends on contract renewal. The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. Limitations, copayments and restrictions may apply. Benefits, premium and/or copayments/coinsurance may change January 1 of each year.