2014 Part D Drug Benefits for Prime (HMO-POS) and Select (PPO) Plans
What you pay for your drugs depends on what “drug payment stage” you are in when you get the drug and which pharmacy you use.
Initial Coverage Stage*
You begin this stage when you fill your first prescription of the year and pay the following cost-shares for covered drugs until your total yearly drug costs (what you pay PLUS what the plan pays) reach $2,850.
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Your share of the cost when you get a one-month (30-day) supply (or less) of a covered Part D prescription drug from:
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Your share of the cost when you get a long-term (90-day) supply of a covered Part D prescription drug from:
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Network Pharmacy
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The plan’s mail order service
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Network long-term care pharmacy
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Out-of-network Pharmacy
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Network Pharmacy
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The plan’s mail order service
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Cost Share Tier 1 - preferred generic drugs and select preferred brand name drugs
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Preferred Network
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$0
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N/A
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N/A
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N/A
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$0
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N/A
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Non-preferred Network
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$4
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$4
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$4
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$4 plus the cost difference between the Network and Non-Network Pharmacy
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$12
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$10
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Cost Share Tier 2 – non-preferred generic drugs and select preferred brand name drugs
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Preferred Network
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$6
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N/A
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N/A
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N/A
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$18
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N/A
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Non-preferred Network
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$10
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$10
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$10
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$10 plus the cost difference between the Network and Non-Network Pharmacy
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$30
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$25
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Cost Share Tier 3 – preferred brand name drugs and select non-preferred generic drugs
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Preferred Network
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$40
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N/A
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N/A
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N/A
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$120
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N/A
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Non-preferred Network
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$45
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$45
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$45
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$45 plus the cost difference between the Network and Non-Network Pharmacy
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$135
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$112.50
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Cost Share Tier 4 – non-preferred brand name drugs and select non-preferred generic drugs
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Preferred Network
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$90
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N/A
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N/A
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N/A
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$270
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N/A
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Non-preferred Network
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$90
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$90
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$90
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$90 plus the cost difference between the Network and Non-Network Pharmacy
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$270
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$225
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Cost Share Tier 5 – specialty drugs
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Preferred Network
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33%
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N/A
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N/A
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N/A
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33%
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N/A
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Non-preferred Network
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33%
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33%
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33%
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33% plus the cost difference between the Network and Non-Network Pharmacy
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33%
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33%
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Coverage Gap Stage*
After your total yearly drug costs (what you pay PLUS what the plan pays) reach $2,850, you will pay 47.5% of the price for brand name drugs and pay 72% of the plan's costs for all generic drugs until your yearly out-of-pocket drug costs reach $4,550.
Catastrophic Coverage Stage*
After your yearly out-of-pocket drug costs reach $4,550, you pay:
For Generics (including brand drugs treated as generic) The greater of $2.55 or a 5% coinsurance
For All Other Drugs The greater of $6.35 or a 5% coinsurance
*Different cost-sharing applies for Members who receive “Extra Help” (Low-Income Subsidy (LIS/LICS))