PHP, California

Rachel Sakai
AHF Provider

Prescription Drugs

PHP (HMO SNP) includes a prescription drug benefit that, like its medical benefits, is designed around the needs of people with HIV. Two key features of the benefit is a $0 Part D premium for 2021 and 2022 and the plan’s formulary (list of covered drugs). PHP prices antiretrovirals (ARVs) at the same cost sharing as it does for common generic drugs, something most other Medicare Advantage and prescription drug plans do not do.

Take a look at the current  2021 Comprehensive Formulary (effective October 1, 2021; last updated September 24, 2021) and the 2022 Comprehensive Formulary (effective January 1, 2022; last updated September 21, 2021). PHP covers both brand name drugs and generic drugs. Generic drugs have the same active-ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs. There are generic drug substitutes available for many brand name drugs.

For 2021 and 2022, PHP has a no-cost (0% coinsurance) drug tier (Tier 5) in its prescription drug benefit that include select care drugs such as high blood pressure, cholesterol and diabetes management drugs.

PHP’s 2021 prescription drug cost-sharing for Medicare beneficiaries who do not receive “Extra Help” (low income subsidy) from Medicare is shown below.

Stage 1
Yearly Deductible Stage

Stage 2
Initial Coverage Stage

Stage 3
Coverage Gap Stage

Stage 4
Catastrophic Coverage Stage

You begin in this payment stage when you fill your first prescription of the year. During this stage you pay the full cost of your tier 1 through 4 drugs.

You stay in this stage until you have paid $445 for your drugs ($445 is the amount of your deductible).

During this stage, you pay coinsurance for covered drugs in tiers 1 through 4 as follows:

  • Tier 1 – 15%
  • Tier 2 – 15%
  • Tier 3 – 25%
  • Tier 4 – 25%

You stay in this stage until your year-to-date “total drug costs” (your payments plus any Part D plan’s payments) total $4,130.

During this stage, you pay 25% of the price for brand name drugs (plus a portion of the dispensing fee) and 25% of the price for generic drugs for your tier 1 through 4 drugs.

You stay in this stage until your year-to-date “out-of-pocket costs” (your payments) reach a total of $6,550.

During this stage, you pay the greater of 5% coinsurance, $3.70 copayment for a generic drug or a drug that is treated like a generic, or $9.20 copayment for all other drugs for your tier 1 through 4 drugs for the rest of the calendar year.

 

PHP’s 2022 prescription drug cost-sharing for Medicare beneficiaries who do not receive “Extra Help” (low income subsidy) from Medicare is shown below.

Stage 1
Yearly Deductible Stage

Stage 2
Initial Coverage Stage

Stage 3
Coverage Gap Stage

Stage 4
Catastrophic Coverage Stage

You begin in this payment stage when you fill your first prescription of the year. During this stage you pay the full cost of your tier 1 through 4 drugs.

You stay in this stage until you have paid $480 for your drugs ($480 is the amount of your deductible).

During this stage, you pay coinsurance for covered drugs in tiers 1 through 4 as follows:

  • Tier 1 – 15%
  • Tier 2 – 15%
  • Tier 3 – 25%
  • Tier 4 – 25%

You stay in this stage until your year-to-date “total drug costs” (your payments plus any Part D plan’s payments) total $4,430.

During this stage, you pay 25% of the price for brand name drugs (plus a portion of the dispensing fee) and 25% of the price for generic drugs for your tier 1 through 4 drugs.

You stay in this stage until your year-to-date “out-of-pocket costs” (your payments) reach a total of $7,050.

During this stage, you pay the greater of 5% coinsurance, $3.95 copayment for a generic drug or a drug that is treated like a generic, or $9.85 copayment for all other drugs for your tier 1 through 4 drugs for the rest of the calendar year.

 

You can also see the 2021 Summary of Benefits and 2022 Summary of Benefits for more information.

If you receive “Extra Help” from Medicare, the above cost sharing does not apply to you.  Your cost sharing is much lower depending on the amount of “Extra Help” you get from Medicare.  Please see the 2021 Premium Summary Table for Medicare Beneficiaries who get “Extra Help” and the 2022 Premium Summary Table for Medicare Beneficiaries who get “Extra Help”for information about the plan’s premium.

PHP has added benefits that Original Medicare doesn’t offer.  Take a look…


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