Pharmacy coverage – Part D

Prescription benefits for the Providence Medicare Advantage plans in your area are split into three phases as noted below. Your costs in Phase I depend on the plan you choose. Your costs in Phase 2 and 3 are the same regardless of the plan you choose.

How it works

Initial Coverage  Coverage Gap  Catastrophic Coverage 
Phase 1 Phase 2 Phase 3
When the total paid by you and the plan reaches $3,700, Phase 2 begins. You pay only 40% of the costs of the brand name drugs and 51% of the costs of generic drugs.

You stay in this phase until your out-of-pocket costs reach $4,950. After that Phase 3 begins.
You pay whichever of these is larger: either 5% coinsurance for the costs of the drug

OR

$3.30 copay for generic drugs, $8.25 copay for brand name or specialty drugs.

What you pay in Phase 1

Prescription drug coverage Providence Medicare
Extra + Rx (HMO)
Providence Medicare Choice + Rx (HMO-POS) Providence Medicare
Prime + Rx (HMO-POS)
Annual deductible $0 $100 $200
One-month supply
Preferred network pharmacy Network pharmacy Preferred network pharmacy Network pharmacy Preferred network pharmacy Network pharmacy
1- Preferred generic $6 $12 $6 $12 $7 $12
2- Generic $15 $20 $15 $20 $15 $20
3- Preferred brand $47 $47 $47
4- Non-preferred drugs 25% 25% 25%
5- Specialty drugs 33% 30% 29%
Three-month supply
Preferred network pharmacy Network pharmacy Preferred network pharmacy Network pharmacy Preferred network pharmacy Network pharmacy
1- Preferred generic $14.40 $36 $14.40 $36 $16.80 $36
2- Generic $36 $60 $36 $60 $36 $60
3- Preferred brand $112.80 $141 $112.80 $141 $112.80 $141
4- Non-preferred drugs 25% 25% 25%
5- Specialty drugs Available in one-month supplies only

Note: Beneficiaries must use network pharmacies to access their prescription drug benefit, except in non-routine circumstances.

Quantity limitations and restrictions may apply.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. The pharmacy network may change at any time. You will receive notice when necessary. You must continue to pay your Medicare Part B premium.