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 low Part D premium in 2018 and no part D premium in 2019 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 2018 Comprehensive Formulary (effective November 1, 2018; last updated October 24, 2018) and the 2019 Comprehensive Formulary (effective January 1, 2019; last updated August 28, 2018).  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.

PHP’s prescription drug cost-sharing for Medicare beneficiaries who do not receive “Extra Help” (low income subsidy) from Medicare is shown below for plan year 2019.

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 drugs.

You stay in this stage until you have paid $415 for your drugs ($415 is the amount of your deductible).

During this stage, you pay 25% coinsurance for all covered drugs (regardless of what tier they are on).

You stay in this stage until your year-to-date “total drug costs” (your payments plus any Part D plan’s payments) total $3,820.

During this stage, you pay 25% of the price for brand name drugs (plus a portion of the dispensing fee) and 37% of the price for generic drugs.

You stay in this stage until your year-to-date “out-of-pocket costs” (your payments) reach a total of $5,100.

During this stage, you pay the greater of 5% coinsurance, $3.40 copayment for a generic drug or a drug that is treated like a generic, or $8.50 copayment for all other drugs for your drugs for the rest of the calendar year.

 

PHP’s prescription drug cost-sharing for Medicare beneficiaries who do not receive “Extra Help” (low income subsidy) from Medicare is shown below for plan year 2018.

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 drugs.

You stay in this stage until you have paid $405 for your drugs ($405 is the amount of your deductible).

During this stage, you pay 25% coinsurance for all covered drugs (regardless of what tier they are on).

You stay in this stage until your year-to-date “total drug costs” (your payments plus any Part D plan’s payments) total $3,750.

During this stage, you pay 35% of the price for brand name drugs (plus a portion of the dispensing fee) and 44% of the price for generic drugs.

You stay in this stage until your year-to-date “out-of-pocket costs” (your payments) reach a total of $5,000.

During this stage, you pay the greater of 5% coinsurance, $3.35 copayment for a generic drug or a drug that is treated like a generic, or $8.35 copayment for all other drugs for your drugs for the rest of the calendar year.

 

This information is not a complete description of benefits.  Call (800) 263-0067 (TTY 711) for more information.  You can also see the 2018 Summary of Benefits and 2019 Summary of Benefits for more information.

PHP has $35.50 Part D premium in 2018.  If you receive “Extra Help” from Medicare, the aforementioned 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 2018 Premium Summary Table for Medicare beneficiaries who get “Extra Help” and the 2019 Premium Summary Table for Medicare Beneficiaries who get “Extra Help” for information about the plan’s premium.

If you do not qualify for 100% premium assistance from Medicare’s “Extra Help” program, you may be eligible for the Medicare Part D Premium Payment Assistance Program (MDPP) from the California AIDS Drug Assistance Program (ADAP) to help pay PHP’s 2018 premium.  The MDPP pays Part D premiums for persons living with HIV who are enrolled in both a Medicare plan with Part D coverage, which PHP is, and ADAP.  Learn more about the MDPP.  (By clicking on this link you will be taken to the California ADAP website operated by California Department of Public Health, Division of AIDS, which is not affiliated with AIDS Healthcare Foundation or PHP (HMO SNP).)

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


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