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Drugs Covered Under
Medicare Part B
General
10% of the cost for Part B-covered chemotherapy
drugs and other Part B-covered drugs.
Drugs Covered Under
Medicare Part D
General
This plan uses a formulary. The plan
will send you the formulary. You can also see the formulary at
www.kelseycareadvantage. com on the
web.
Different out-of-pocket costs may apply
for people who
- have limited incomes,
- live in long term care facilities,
or
- have access to Indian/Tribal/Urban
(Indian Health Service).
The plan offers national in-network
prescription coverage (i.e., this would include 50 states and DC). This means that
you will pay the same cost-sharing amount for your prescription drugs if you get
them at an in-network pharmacy outside of the plan’s service area (for instance
when you travel).
Total yearly drug costs are the total
drug costs paid by both you and the plan.
The plan may require you to first try
one drug to treat your condition before it will cover another drug for that condition.
Some drugs have quantity limits.
Your provider must get prior authorization
from KelseyCare Advantage Rx+Choice (HMO-POS) for certain drugs.
You must go to certain pharmacies for
a very limited number of drugs, due to special handling, provider coordination,
or patient education requirements that cannot be met by most pharmacies in your
network. These drugs are listed on the plan’s website, formulary, printed materials,
as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov.
If the actual cost of a drug is less
than the normal cost-sharing amount for that drug, you will pay the actual cost,
not the higher
cost-sharing amount.
If you request a formulary exception
for a drug and KelseyCare Advantage Rx+Choice (HMO-POS) approves the exception,
you will pay Tier 4: Non-Preferred Brand Drugs cost sharing for that drug.
In-Network
$0 deductible
Initial Coverage
You pay the following until total yearly
drug costs reach $2,840:
Retail Pharmacy
Tier 1: Preferred Generic Drugs
-
$3 copay for a one-month (30-day) supply
of drugs in this tier from a preferred pharmacy
-
$7.50 copay for a three-month (90-day)
supply of drugs in this tier from a preferred pharmacy
-
$8 copay for a one-month (30-day) supply
of drugs in this tier from a non-preferred pharmacy
-
$24 copay for a three-month (90-day)
supply of drugs in this tier from a non-preferred pharmacy
Tier 2: Non-Preferred Generic Drugs
-
$30 copay for a one-month (30-day) supply
of drugs in this tier from a preferred pharmacy
-
$75 copay for a three-month (90-day)
supply of drugs in this tier from a preferred pharmacy
-
$40 copay for a one-month (30-day) supply
of drugs in this tier from a non-preferred pharmacy
-
$120 copay for a three-month (90-day)
supply of drugs in this tier from a non-preferred pharmacy
Tier 3: Preferred Brand Drugs
-
$30 copay for a one-month (30-day) supply
of drugs in this tier from a preferred pharmacy
-
$75 copay for a three-month (90-day)
supply of drugs in this tier from a preferred pharmacy
-
$40 copay for a one-month (30-day) supply
of drugs in this tier from a non-preferred pharmacy
-
$120 copay for a three-month (90-day)
supply of drugs in this tier from a non-preferred pharmacy
Tier 4: Non-Preferred Brand Drugs
-
$60 copay for a one-month (30-day) supply
of drugs in this tier from a preferred pharmacy
-
$150 copay for a three-month (90-day)
supply of drugs in this tier from a preferred pharmacy
-
$70 copay for a one-month (30-day) supply
of drugs in this tier from a non-preferred pharmacy
-
$210 copay for a three-month (90-day)
supply of drugs in this tier from a non-preferred pharmacy
Tier 5: Specialty Tier Drugs
-
33% coinsurance for a one-month (30-day)
supply of drugs in this tier from a preferred pharmacy
-
33% coinsurance for a three-month (90-day)
supply of drugs in this tier from a preferred pharmacy
-
33% coinsurance for a one-month (30-day)
supply of drugs in this tier from a non-preferred pharmacy
-
33% coinsurance for a three-month (90-day)
supply of drugs in this tier from a non-preferred pharmacy
Long Term Care Pharmacy
Tier 1: Preferred Generic Drugs
-
$8 copay for a one-month (31-day) supply
of drugs in this tier
Tier 2: Non-Preferred Generic Drugs
-
$40 copay for a one-month (31-day) supply
of drugs in this tier
Tier 3: Preferred Brand Drugs
-
$40 copay for a one-month (31-day) supply
of drugs in this tier
Tier 4: Non-Preferred Brand Drugs
-
$70 copay for a one-month (31-day) supply
of drugs in this tier
Tier 5: Specialty Tier Drugs
-
33% coinsurance for a one-month (31-day)
supply of drugs in this tier
Additional Coverage Gap
You pay the following:
Retail Pharmacy
Tier 1: Preferred Generic Drugs
-
$3 copay for a one-month (30-day) supply
of all drugs covered in this tier from a preferred pharmacy
-
$7.50 copay for a three-month (90-day)
supply of all drugs covered in this tier from a preferred pharmacy
-
$8 copay for a one-month (30-day) supply
of all drugs covered in this tier at a non-preferred pharmacy
-
$24 copay for a three-month (90-day)
supply of all drugs covered in this tier from a non-preferred pharmacy
Long Term Care Pharmacy
Tier 1: Preferred Generic Drugs
-
$8 copay for a one-month (31-day) supply
of all drugs covered in this tier
After your total yearly drug costs reach
$2,840, you receive limited coverage by the plan on certain drugs. You will also
receive a discount on brand name drugs and generally pay no more than 93% of the
plan’s costs for generic drugs until your yearly out-of-pocket drug costs reach
$4,550.
Catastrophic Coverage
After your yearly out-of-pocket drug
costs reach $ 4,550, you pay the greater of:
-
A $ 2.50 copay for generic (including
brand drugs treated as generic) and a $6.30 copay for all other drugs, or;
- 5% coinsurance.
Out-of-Network
Plan drugs may be covered in special
circumstances, for instance, illness while traveling outside of the plan’s service
area where there is no network pharmacy. You may have to pay more than your normal
cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition,
you will likely have to pay the pharmacy’s full charge for the drug and submit documentation
to receive reimbursement from KelseyCare Advantage Rx+Choice (HMO-POS).
Out-of-Network Initial Coverage
You will be reimbursed up to the full
cost of the drug minus the following for drugs purchased out-of-network until total
yearly drug costs reach $2,840:
Tier 1: Preferred Generic Drugs
-
$8 copay for a one-month (30-day) supply
of drugs in this tier
Tier 2: Non-Preferred Generic Drugs
-
$40 copay for a one-month (30-day) supply
of drugs in this tier
Tier 3: Preferred Brand Drugs
-
$40 copay for a one-month (30-day) supply
of drugs in this tier
Tier 4: Non-Preferred Brand Drugs
-
$70 copay for a one-month (30-day) supply
of drugs in this tier
Tier 5: Specialty Tier Drugs
-
33% coinsurance for a one-month (30-day)
supply of drugs in this tier
You will not be reimbursed for the difference
between the Out-of-Network Pharmacy charge and the plan’s In-Network allowable amount.
Additional Out-of-Network Coverage
Gap
You will be reimbursed for these drugs
purchased out-of-network up to the full cost of the drug minus the following:
Tier 1: Preferred Generic Drugs
-
$8 copay for a one-month (30-day) supply
of all drugs covered in this tier
Tier 2: Non-Preferred
Generic Drugs
-
You will be reimbursed up to 7% of the
plan allowable cost for generic drugs purchased out-of-network until total yearly
drug costs reach $4,550.
You will be reimbursed up to the discounted
price for brand name drugs purchased out-of-network until total yearly drug costs
reach $4,550.
Tier 3: Preferred Brand Drugs
-
You will be reimbursed up to 7% of the
plan allowable cost for generic drugs purchased out-of-network until total yearly
drug costs reach $4,550.
You will be reimbursed up to the discounted
price for brand name drugs purchased out-of-network until total yearly drug costs
reach $4,550.
Tier 4: Non-Preferred Brand Drugs
-
You will be reimbursed up to 7% of the
plan allowable cost for generic drugs purchased out-of-network until total yearly
drug costs reach $4,550.
You will be reimbursed up to the discounted
price for brand name drugs purchased out-of-network until total yearly drug costs
reach $4,550.
Tier 5: Specialty Tier Drugs
-
You will be reimbursed up to 7% of the
plan allowable cost for generic drugs purchased out-of-network until total yearly
drug costs reach $4,550.
You will be reimbursed up to the discounted
price for brand name drugs purchased out-of-network until total yearly drug costs
reach $4,550.
You will not be reimbursed for the difference
between the Out-of-Network Pharmacy charge and the plan’s In-Network allowable amount.
Out-of-Network Catastrophic Coverage
After your yearly out-of-pocket drug
costs reach $ 4,550, you will be reimbursed for drugs purchased out-of-network up
to the full cost of the drug minus your cost share, which is the greater of:
-
A $ 2.50 copay for generic (including
brand drugs treated as generic) and a $ 6.30 copay for all other drugs, or
-
5% coinsurance.
You will not be reimbursed for the difference
between the Out-of-Network Pharmacy charge and the plan’s In-Network allowable amount.
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