As you manage your prescriptions, it helps to know how the different pieces of your Medicare Part D coverage fit together.
Prescription coverage comes with a few key terms that explain how your plan works. To make the most of your prescription coverage and avoid unexpected costs at the pharmacy, it's helpful to know what they mean and how they affect what you pay.
- Deductible: Your deductible is the amount of money you pay for medication before your insurance starts paying.
- Copay: A copay is the fixed amount you pay for a prescription.
- Coinsurance: Coinsurance is the percentage of your medication's cost that you’ll pay. Unlike a copay, your coinsurance cost will change depending on the medicine and if you've reached your deductible.
- Tier: Tiers are the way medications are grouped on your Formulary (list of covered drugs).
- Part D out-of-pocket maximum: The annual limit on how much you pay out-of-pocket for covered Part D prescription medications.
There are three stages of coverage for your prescription drugs during the year. Each stage affects how much you pay for your medication. Here’s a quick overview of how it works and what you can expect during each stage.
A set dollar amount on certain medicines that you must pay first before your plan starts paying. Your deductible depends on your plan, but generally ranges from $0 to $615.
The deductible may not apply to certain tiers. It also doesn’t apply to covered insulin products and most adult Part D vaccines, like those for shingles, tetanus and travel.
Your plan pays its share of the cost of your covered medications. You pay your share (your copayment or coinsurance amount). Your share will vary depending on the medicine, tier, and pharmacy.
You stay in the initial coverage stage until your total out-of-pocket costs reach $2,100.
You enter the catastrophic coverage stage when your out-of-pocket costs reach the $2,100 limit for the calendar year. Remember, once you’re in this stage, you pay nothing for covered Part D medications.
You’ll stay in this payment stage until the end of the calendar year.
Let's take a look at how these terms and stages all work together by seeing how it works in a real-life situation.
For this example, your Medicare plan has a $615 deductible. It has a $0 copay for medications in Tiers 1 and 2. For Tier 3, 4, and 5 medications, the plan has a 25% coinsurance, meaning you pay 25% of the medication cost. You can find a drug's tier in your Formulary (list of covered drugs) or by using the drug search.
- It’s your first fill of the year.
- Your medication costs $1,000.
- It’s a Tier 3 medication.
You’d pay $615 to meet your deductible.
You’d also pay 25% of the remaining $385, which is $96.25.
$615 + $96.25 = $711.25
- You’re refilling the same Tier 3 medication.
- The medication costs $1,000.
Your deductible is met, so you pay $0.
You’d pay 25% of $1,000, which is $250.
$0 + $250 = $250
- You’re refilling the same Tier 3 medication.
- The medication costs $1,000.
- Your out-of-pocket maximum of $2,100 has been met.
Your deductible is met, so you pay $0.
Because you've reached your out-of-pocket maximum, you pay $0 for this medication.
You pay $0 for the medication because you've met your deductible and out-of-pocket maximum.
Our plan keeps track of your prescription drug costs and the payments you make when you get prescriptions at the pharmacy. This way, we can tell you when you've moved from one coverage stage to the next. We share that information each month in your Part D Explanation of Benefits (EOB).
The EOB includes information for that month, totals for the year since January 1, drug price information, and lower-cost prescription options.
Review a sample Part D EOB (PDF) to see how your monthly prescription drug spending is tracked and detailed.
There are several choices you can make that could help you save money on your medication.
You may have options when filling your medication. Our plans allow for 90-day supplies at select pharmacies in our network. A 30-day supply may be less expensive upfront than a 90-day supply, but a 90-day supply at a preferred mail-order pharmacy may help you save with long-term costs.
When managing chronic conditions like high blood pressure, diabetes, or high cholesterol, filling a 90-day supply may be a convenient way to help you save money and stay on track with your treatment plan.
Your costs for some drugs may be less at pharmacies that offer preferred cost-sharing. This is known as our Preferred Pharmacy network. Blue Cross NC's preferred retail pharmacies include Harris Teeter, Sam's Club, Walgreens, and Walmart and some independent pharmacies.
Experience Health Medicare Advantage℠ (HMO) and Healthy Blue + Medicare℠ (HMO-POS D-SNP) members do not have a Preferred Retail Pharmacy network. Members of these plans may go to any retail pharmacy in their network.
Amazon Pharmacy is our preferred mail-order pharmacy. You can get the convenience of an up to 90-day medication supply delivered right to your home. Experience Health Medicare Advantage℠ (HMO) and Healthy Blue + Medicare℠ (HMO-POS D-SNP) members do not have a preferred mail-order pharmacy network. Members of this plan may use any mail-order pharmacy in their network.
If you’re taking a brand-name medication, speak with your doctor or pharmacist to learn about generic options. Generic medications have the same active ingredient as the brand-name medication but usually cost less.
If your medication is in a cost-sharing tier you think is too high, talk to your doctor. Switching to a different medication in a lower cost-sharing tier may be an option. Or your doctor can help you request a tier exception for medical reasons. A tier exception, a type of coverage determination, can help to lower costs.
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
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