How Your Prescription Drug Coverage Works
Your Elderplan Advantage for Nursing Home Residents (HMO-POS I-SNP) plan includes Medicare Part D prescription drug coverage — there is nothing extra to sign up for.
Your drug costs at a glance
| $22.40 monthly Part D premiumMembers who get Extra Help may pay less. | $700 deductibleApplies to all drugs except covered insulin products and most adult Part D vaccines. | $2,400 yearly out-of-pocket maximumOnce you reach it, you pay $0 for covered Part D drugs for the rest of the year. |
With this plan, what you pay for most drugs is coinsurance — a percentage of the drug’s cost — not a fixed copay. You pay the same 25% share whether the drug is generic or brand-name.
| Your drugs | One-month supply (retail or long-term care) | Up to a 90-day supply (retail or mail-order) |
|---|---|---|
| Generic drugs (including brand drugs treated as generic) | 25% coinsurance | 25% coinsurance |
| All other drugs | 25% coinsurance | 25% coinsurance |
| Covered insulin | No more than $35 for a one-month supply | No more than $70 (2-month) or $105 (3-month) |
Specialty drugs may be limited to a 30-day supply per fill. A 60-day supply is also available at standard retail pharmacies. If you get “Extra Help” paying for your drugs, your costs may be lower — see your Low-Income Subsidy (LIS) Rider.
How your coverage works throughout the year
Your prescription drug benefit follows three simple stages.
- You start with the deductible.
- You pay the full cost of your covered drugs until you have paid $700.
- The deductible does not apply to covered insulin products or most adult Part D vaccines (like shingles, tetanus, and travel vaccines) — you skip the deductible for those.
- You pay your regular share of the cost.
- Once your deductible is met, you pay 25% coinsurance for your covered drugs. You will never pay more than $35 for a one-month supply of a covered insulin product, even before you meet the deductible.
- Once you reach your yearly limit, covered drugs are $0.
- After your out-of-pocket drug costs reach $2,400, you pay nothing for covered Part D drugs through December 31.
- We will let you know when you reach this stage.
How to Use Your Prescription Drug Benefit
Filling a prescription under your plan is straightforward. You do not need a referral from your Primary Care Provider.
- Use a network pharmacy. In most cases, your prescriptions are covered only when filled at a network pharmacy. If you live in a nursing home or other long-term care facility, you usually use the facility’s pharmacy — confirm that it is in our network at elderplan.org, or call Member Services if you have any trouble getting your drugs.
- Bring your prescription and your Elderplan card. Show your Elderplan Member ID card — not your red, white, and blue Medicare card — at every pharmacy visit. If you also have Medicaid, show your Medicaid card too.
- Check whether your drug is on the Drug List. Use the Search for a Covered Drug tool to confirm your medication is covered and to check whether any coverage rules — prior authorization, step therapy, or quantity limits — apply.
- Consider mail-order for medications you take regularly. Through CVS Caremark, you can get up to a 90-day supply of maintenance drugs delivered to your door. Call 1-866-490-2102 (TTY: 711), available 24/7, or visit Caremark.com.
Coverage Rules: When Drugs Require Prior Authorization
Some prescription drugs may require additional review before your plan can cover them. These requirements are called coverage rules.
Coverage rules are designed to help ensure that medications are used safely, appropriately, and in accordance with clinical guidelines. If a coverage rule is keeping you from getting the medication you need, you have rights and options. Learn more about Coverage Rules.
If you get “Extra Help” from Medicare (also called the Low-Income Subsidy), your drug costs may be lower than the amounts shown here. Please refer to your LIS Rider, or call Member Services at 1-800-353-3765 (TTY: 711) to ask for