Medicare Part D Prescription Drug Coverage - 2019

Generations Advantage Prime (HMO-POS)Select (PPO) Value Plus (HMO)Focus DC (HMO SNP) , and Flex (RPPO) plans have Part D prescription drug coverage built right into the plan. Your prescription coverage is included in your premium and there are no deductibles to meet. With your very first prescription, you only pay a small copayment or coinsurance. The copayment/coinsurance is determined by what type of drug you are receiving as well as which pharmacy you choose to use.

Pharmacies with preferred cost-sharing*—For a 30-day supply of medication filled at a pharmacy with preferred cost-sharing* the cost of Preferred Generic (Tier 1) is $0 (Flex plan $2) , Generic (Tier 2) is $10, Preferred Brand (Tier 3) is $40, Non-Preferred Drug (Tier 4) is $95. For Specialty Tier (Tier 5) Prime, Select, and Focus DC members pay a 33% coinsurance. Value Plus members pay a 28% coinsurance and Flex members pay a 27% coinsurance.  

Pharmacies with standard cost-sharing—For a 30-day supply of medication filled at pharmacies with standard cost-sharing the cost of Preferred Generic (Tier 1) is $4, Generic (Tier 2) is $18, Preferred Brand (Tier 3) is $47, Non-Preferred Drug (Tier 4) is $100. For Specialty Tier (Tier 5) Prime, Select, and Focus DC members pay a 33% coinsurance. Value Plus members pay a 28% coinsurance and Flex members pay a 27% coinsurance.

For a table showing the pharmacy copayment levels please see the Pharmacy Benefit Copayment Overview page.

You can also save more by ordering a 90-day supply of your maintenance medications through the Martin’s Point Generations Advantage mail-order pharmacy, operated by CVS Caremark.

Through the mail-order pharmacy, it generally takes us 10—14 days to process your order and ship it to you. However, sometimes your mail-order may be delayed. If your mail-order shipment is delayed and you need your prescription immediately, the mail-order service will work with you to ensure that you receive your prescription. The mail-order prescription service will either expedite your order or have it filled locally. If your medication must be taken immediately, ask your physician to issue two prescriptions—one for a short supply to be filled at your local pharmacy, and a second for an extended supply to be mailed to the mail-order prescription drug service.  If you feel your mail-order may be delayed, you can call  the mail-order customer service line at 1-888-296-6961

* Use the Pharmacy Search tool to find a preferred network pharmacy for Martin's Point Generations Advantage plan members with prescription drug coverage.

If you have questions about how much specific medications will cost under your plan, you can search our online drug list or call Member Services at 1-866-544-7504 (TTY: 711), 8 am-8 pm, seven days a week from October 1 to March 31, and Monday through Friday the rest of the year. 

For more information on coverage determinations, including exceptions, grievances, and appeals processes, please see the Evidence of Coverage for your plan. For Prime (HMO-POS), Select (PPO), Value Plus (HMO) Focus DC (HMO SNP) and Flex (RPPO) plans, look at Chapter 9 of the Evidence of Coverage. For Value (HMO) plan, see Chapter 7 of the Evidence of Coverage. You can access the Evidence of Coverage here. 

You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day / 7 days a week; the Social Security Office at 1-800-772-1213 7 am-7 pm, Monday through Friday. TTY users should call, 1-800-325-0778; or your Medicaid Office. You must use network pharmacies to access their prescription drug benefit, except in nonroutine circumstances, and quantity limitations and restrictions may apply.

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