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
There is a $100 deductible for KelseyCare Advantage Signature plan members on Tier 3, Tier 4, and Tier 5 drugs.
Initial Coverage
You pay the following until your total yearly drug cost reaches $2,000. When you (or those paying on your behalf) have spent a total of $2,000 in out-of-pocket costs within the calendar year, you will move from the Initial Coverage Stage to the Catastrophic Coverage Stage. You may get your drugs at network retail and mail-order pharmacies.
| Preferred Retail Cost-Sharing* |
| Tier |
30-Day Supply |
60-Day Supply |
90-Day Supply |
| Tier 1 (Preferred Generic) |
$0 |
$0 |
$0 |
| Tier 2 (Generic) |
$5 |
$10 |
$12.50 |
| Tier 3 (Preferred Brand) |
$40 |
$80 |
$100 |
| Tier 4 (Non-Preferred Drug) |
40% |
40% |
40% |
| Tier 5 (Specialty Tier) |
30% |
N/A |
N/A |
| Tier 6 (Select Care Drugs) |
$0 |
$0 |
$0 |
| Covered Insulins |
$35 |
$70 |
$87.50 |
* The preferred cost-sharing pharmacies in the Greater Houston area include Kelsey Pharmacy, HEB Pharmacies, CVS retail locations.
| Standard Retail Cost-Sharing |
| Tier |
30-Day Supply |
60-Day Supply |
90-Day Supply |
| Tier 1 (Standard Generic) |
$7 |
$14 |
$21 |
| Tier 2 (Generic) |
$15 |
$30 |
$45 |
| Tier 3 (Standard Brand) |
$47 |
$94 |
$141 |
| Tier 4 (Non-Standard Drug) |
40% |
40% |
40% |
| Tier 5 (Specialty Tier) |
30% |
N/A |
N/A |
| Tier 6 (Select Care Drugs) |
$0 |
$0 |
$0 |
| Select Insulins* |
$35 |
$70 |
$105 |
| Benefit |
Description |
| Mail Order |
Yes |
Yes |
Yes |
| Covered Insulins |
You won’t pay more than $35 for a one-month supply of each covered insulin product regardless of the cost-sharing tier, even if you haven’t paid your deductible.
|
Catastrophic Coverage Stage
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000, you pay
- Your plan pays the full cost for your covered Part D drugs. You pay nothing.
- For excluded drugs covered under our enhanced benefit, you continue paying your Initial Coverage Stage cost-share.
Additional Prescription Drug Benefits
Select Care Drugs Tier
KelseyCare Advantage is ensuring you have easy access to many of the vaccines you need and drugs you take to treat high blood pressure, high cholesterol and diabetes – all at a $0 copay!
Tier 6 covers Medicare Select Care Drugs at a $0 copay, all year long, at any network pharmacy including:
Vaccines
33 vaccinations and counting that protect you from serious disease and illness.
Maintenance Medications
46 generic oral medications prescribed most to help you manage chronic conditions. Tier 6 drugs are covered at $0 copay all year.
Excluded Drug Coverage
We offer additional coverage of some prescription drugs not normally covered in a Medicare prescription drug plan (enhanced drug coverage). This includes coverage of certain drugs excluded from Medicare Part D Coverage.
As part of the plan's enhanced drug coverage for Calendar Year 2025, payments you make for excluded drugs are not included in your out-of-pocket costs.
The covered excluded drugs in 2025 are listed below
| Drug Name |
Tier |
Drug Restrictions |
| sildenafil 25 MG, 50 MG and 100 MG Tablet |
2 |
Quantity Limit of 6 Tablets every 30 days |
| folic acid 1 MG Tablet |
2 |
Quantity Limit of 30 Tablets every 30 days |
| ergocalciferol (vitamin D2) 1.25 MG Capsule |
2 |
N/A |
| vitamin B12 1000 MCG/ML Injection |
2 |
N/A |
