After the total combined plan and member drug cost equals $3,820, the coverage gap starts. During this stage, you will pay 25% of the price for brand name drugs (plus a portion of the dispensing fee) and 37% of the price for generic drugs until your total out-of-pocket costs reach $5,100.
After your yearly out-of-pocket costs reach $5,100 (including your retail and mail-order pharmacy), you pay the greater of:
Coinsurance of 5% of the cost of the drug, OR
$3.40 for a generic drug (or drug that is treated like a generic) and $8.50 for all other drugs.
Coverage level shown does not reflect standard pharmacy cost shares or mail-order pharmacy cost shares. Please refer to your 2019 Summary of Benefits for additional coverage details.
You can read more here about Part D Coverage determination, Exceptions, Appeals, and Grievances.
Our Medicare Advantage (HMO), Classic (HMO), Classic Plus (HMO), Total Health (HMO), and Core (HMO) plans can be found here:
Step Therapy Criteria
Prior Authorization Criteria
Our Sound + Rx (HMO), Peak + Rx (HMO), Charter + Rx (HMO) can be found here:
Use the following form when requesting prior authorization
Prior Authorization form
If you don’t enroll in Medicare Part D when you’re first eligible and there’s a continuous period of 63 days or more—and you don’t have creditable coverage through an employer-provided plan—you may have to pay a penalty. For each month you delay, you may pay an additional 1% of the average premium per month on top of your regular plan premium as long as you are enrolled in a Part D plan. View the Creditable Coverage and Late Enrollment Penalty page on the Centers for Medicare & Medicaid Services (CMS) website.
The government subsidizes prescription drug costs for members with limited incomes. People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If eligible, Medicare could pay for up to 100% of drug costs including monthly prescription drug premiums, annual deductibles, and coinsurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don't know it. For more information about this extra help, see the LIS Premium Summary Table, contact your local Social Security office, or call 800-MEDICARE (800-633-4227), 24 hours per day, 7 days per week. TTY/TTD users should call 877-486-2048 (TTY/TDD: 711).
CMS created the Best Available Evidence
(BAE) policy in 2006. This policy requires sponsors to establish the appropriate cost-sharing for low-income beneficiaries when presented with evidence that the beneficiary's information is not accurate in CMS's systems. View the CMS Best Available Evidence Policy Information on the CMS website.
The pharmacy network for Premera Blue Cross Medicare Advantage (HMO), Classic (HMO), Classic Plus (HMO), Total Health (HMO), and Core (HMO) includes pharmacies that offer standard cost-sharing and pharmacies that offer preferred cost-sharing. Members of these plans may go to either type of network pharmacy to receive covered prescription drugs. Your cost-sharing may be less at pharmacies with preferred cost-sharing.