Gold

Plan Premium

The monthly fee you pay the plan for your health care. The amount shown does not include the Part B premium you already pay to the government.

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. There is no deductible for Select Insulins. During the Deductible Stage, your out-of-pocket costs for these Select Insulins will be $30 - $35 copay for a 30-day supply. After you pay your yearly deductible, you pay the following until your total yearly drug cost reach $4,430. 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 and mail-order pharmacies.

You may get your drugs at network retail pharmacies.

* The preferred cost-sharing pharmacies in the Greater Houston area include Kelsey Pharmacy, HEB, CVS retail locations and CVS Caremark Mail Service.

Coverage Gap Stage

The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $4,430. After you enter the coverage gap, you pay 25% of the plan’s negotiated price for covered brand name drugs and 25% of the plan’s negotiated price for covered generic drugs until your out-of-pocket costs total $7,050, which is the end of the coverage gap. KelseyCare Advantage offers additional gap coverage for Tier 1 and Tier 2 drugs and Select Insulins. 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 $7,050, you pay the greater of:

• 5% of the plan’s negotiated price, or
• $3.95 copay for generic (including brand drugs treated as generic) and a $9.85 copay for all other drugs.

Additional Prescription Drug Benefits

As part of the plan's enhanced drug coverage for Calendar Year 2022, the excluded drug Sildenafil in Tier 2 is covered. Payments you make for excluded drugs are not included in your out-of-pocket costs.

We offer additional coverage of some prescription drugs not normally covered in a Medicare prescription drug plan (enhanced drug coverage).This includes coverage of the following drugs in the Tier 2 cost-sharing tier and have a quantity limit of 6 every 30 days:

• sildenafil 25 MG - QL 6/30 – Tier 2
• sildenafil 50 MG - QL 6/30 – Tier 2
• sildenafil 100 MG - QL 6/30 – Tier 2

The amount you pay when you fill a prescription for these drugs does not count towards drug cost for entering the Coverage Gap Stage nor does it contribute to entering the Catastrophic Coverage Stage.