How Your Prescription Drug Coverage Works
Know What’s Covered and What You May Pay
Your Elderplan for Medicaid Beneficiaries (HMO-POS D-SNP) plan includes Medicare Part D prescription drug coverage; there is nothing extra to sign up for. Most members qualify for Extra Help (Low- Income Subsidy), which covers most or all of their drug costs. This page explains how your coverage works.
Generic Drugs
(including brand drugs treated as generic)
Covered: Your full Part D generic medication list, filled at any network pharmacy or through mail-order delivery
Your cost per prescription: Depending on your level of Extra Help, you pay one of the following:
- [$0] copay
- [$1.65] copay
- [$5.80] copay
- 25% of the total cost
Available in a 30-day, 60-day, or up to 90-day supply at a network pharmacy. Up to a 90-day supply is available by mail-order through CVS Caremark.
Brand-Name & All Other Covered Drugs
Covered: Your full Part D brand-name and specialty medication list, filled at any network pharmacy or through mail-order delivery
Your cost per prescription: Depending on your level of Extra Help, you pay one of the following:
- [$0] copay
- [$5.00] copay
- [$14.40] copay
- 25% of the total cost
Certain specialty drugs are limited to a 30-day supply per fill (marked “NDS” on your Drug List).
Prescription Drug Cost Protections
| Insulin cost cap $35 per month for all members | You will not pay more than [$35] for a one-month supply of any covered insulin product — regardless of your Extra Help level or whether you have met your deductible. A 3-month supply of insulin will not exceed [$105]. This cap applies automatically. No action is needed from you or your provider. |
| Most adult vaccines are [$0] — no deductible, no copay | Most adult Part D vaccines recommended by the CDC’s Advisory Committee on Immunization Practices (ACIP) — including shingles, RSV, and Tdap — are covered at [$0] with no deductible applied. Your flu and COVID-19 vaccines are also [$0] under your medical benefit. |
| Once you reach [$2,400] in out-of-pocket drug costs, you pay [$0] for the rest of the year | This is called the Catastrophic Coverage Stage. Most members with Extra Help never reach this limit because their copays are already so low — but if you do, your plan covers 100% of your covered Part D drugs through December 31. |
How to Use Your Rx Benefit
Filling a prescription under your plan is straightforward. You do not need a referral from your Primary Care Provider.
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Check if your drug is covered
Search to see if your prescription drug is covered and to see if any coverage rules apply.
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Bring your Elderplan Member ID card
Show your Elderplan Member ID card — not your red, white, and blue Medicare card at every pharmacy visit.
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Consider mail-order
You can get up to a 90-day supply delivered to your door at the same low copay.
Things to keep in mind before you fill a prescription:
| Most members pay [$0] for the Part D premium and deductible | The 2027 Part D deductible is [$700], but if you receive Extra Help — as most members of this plan do — your deductible is [$0]. |
| Your exact copay depends on your Extra Help level Some drugs require extra steps | The LIS Rider mailed to you separately shows the specific amounts that apply to your coverage. If you do not have your LIS Rider, call Member Services, and we will send you a copy. Learn more about Extra Help and what it means for you. |
| Some drugs require extra steps | A small number of medications require prior authorization, step therapy, or have quantity limits. Your Drug List will note these rules. If a rule is standing between you and a medication you need, you have the right to request a formulary exception or appeal. → Getting Approval for Your Medications |
| Always use a network pharmacy | Out-of-network pharmacy fills are generally not covered except in limited emergency or travel situations. Use the Find a Pharmacy tool before you travel or if your regular pharmacy is closed. |
| Part B drugs are different | Medications given to you in a doctor’s office, clinic, or infusion center — like chemotherapy or certain injections — are covered under Medicare Part B, not Part D. If you are eligible for Medicare cost-sharing assistance under Medicaid, you pay [$0] for covered Part B drugs. |
Quick Help
If your medication does not appear in the Drug List or a coverage rule is preventing you from getting it, you have options. You or your doctor can request a formulary exception, a coverage determination, or an appeal. Visit the “Getting Approval for Your Medications” page for step-by-step instructions and required forms.
If you take eight or more medications for three or more chronic conditions, you may qualify for the free Medication Therapy Management (MTM) program. If you qualify, we will automatically enroll you and send you information. Visit the MTM page to learn more and see the full list of qualifying conditions.
Visit the “Search for a Rx” page to look up your medication, check your tier, estimate your cost, and see if any coverage rules apply. You can also use the Real-Time Benefit Tool at Caremark.com or call Member Services.