This table gives you basic information about the prescription drug benefits that are available with some of our plans. For more details, see the Comprehensive Formulary (PDF) in the Plan Documents section.
Deductible Stage
You will pay a yearly deductible of $100 on Tiers 3, 4 and 5 drugs. You must pay the full cost of your Tiers 3, 4 and 5 drugs until you reach the plan’s deductible amount. There is no deductible for KelseyCare Advantage for select insulins. During the Deductible Stage, your out-of-pocket costs for these select insulins will be $30-$35 for a 30-day supply. To find out which drugs are select insulins, review the most recent Drug List.
Initial Coverage
You will pay a yearly deductible of $100 on Tiers 3, 4 and 5 drugs. You must pay the full cost of your Tiers 3, 4 and 5 drugs until you reach the plan’s deductible amount. After you pay your yearly deductible, you pay the following until your total yearly drug cost reach $4,130. Total yearly drug costs are the total drug cost paid by both you and our Part D plan.
You may get your drugs at network retail pharmacies.
| Preferred Retail Cost-Sharing* |
| Tier | 30-Day Supply | 90-Day Supply |
| 1 | $0 | $0 |
| 2 | $5 | $12.50 |
| 3 | $40 | $100 |
| Select Insulins: $30 | Select Insulins: $75 |
| 4 | $80 | $200 |
| 5 | 31% | NA |
* The preferred cost-sharing pharmacies in the Greater Houston area include Kelsey Pharmacy, HEB, CVS retail locations and CVS Caremark Mail Service.
| Standard Retail Cost-Sharing |
| Tier | 30-Day Supply | 90-Day Supply |
| 1 | $3 | $9 |
| 2 | $10 | $30 |
| 3 | $45 | $135 |
| Select Insulins: $35 | Select Insulins: $105 |
| 4 | $90 | $270 |
| 5 | 31% | NA |
| Mail Order | Preferred Network Copays Apply |
| Insulin Savings Model | Members pay no more than $35 for 30-day during any coverage stage Preferred Pharmacy: $30 Standard Pharmacy: $35 |
| Stage | Description |
| Coverage Gap Stage | Most Medicare drug plans have a coverage gap (also called the “donut hole”). This means that there’s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $4,130. After you enter the coverage gap, you pay 25% of the plan’s cost for covered brand name drugs and 25% of the plan’s cost for covered generic drugs until your costs total $6,550, which is the end of the coverage gap. Not everyone will enter the coverage gap. Under this plan, you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug’s tier. See the chart that follows to find out how much it will cost you. |
| Catastrophic Coverage Stage | After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $6,550, you pay the greater of: - 5% of the cost, or
- $3.70 copay for generic (including brand drugs treated as generic) and a
- $9.20 copayment for all other drugs.
|
Coverage Gap Stage
Most Medicare drug plans have a coverage gap (also called the “donut hole”). This means that there’s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $4,130.
After you enter the coverage gap, you will continue to pay the initial coverage stage copays for Tiers 1 and 2 medications. For Tiers 3, 4 and 5 medications you will pay 25% of the plan’s cost for covered brand name drugs and 25% of the plan’s cost for covered generic drugs until your costs total $6,550, which is the end of the coverage gap. KelseyCare Advantage offers additional gap coverage for select insulins. During the Coverage Gap stage, your out-of-pocket costs for select insulins will be $30-$35 for a 30-day supply. To find out which drugs are select insulins, review the most recent Drug List. Not everyone will enter the coverage gap. For more information about the Part D Senior Savings model, you can refer to the 2021 Evidence of Coverage (EOC).
Catastrophic Coverage Stage
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $6,550, you pay the greater of: 5% of the cost, or $3.70 copay for generic (including brand drugs treated as generic) and a $9.20 copayment for all other drugs.
