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  • 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 2022 and 2023 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 2022 Comprehensive Formulary (effective December 1, 2022; last updated November 23, 2022) and the 2023 Comprehensive Formulary (effective January 1, 2023; last updated October 7, 2023). 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 2022 and 2023, 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 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.

    PHP’s 2023 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 $505 for your drugs ($505 is the
    amount of your deductible).

    There is no deductible for PHP for Select Insulins.  You pay $35 for a one-month supply of Select Insulins.

    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 pay $35 for Select Insulins.

    You stay in this stage until your year-to-date “total drug costs” (your payments plus any Part D plan’s payments) total $4,660.

    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 $7,400. This amount and rules for counting costs toward this amount have been set by Medicare.

    During the Coverage Gap stage, your out-of-pocket costs for Select Insulins will be $35 for a one-month supply.

    During this stage, you pay the greater of 5% coinsurance or $4.15 copayment for generic and multisource brand drugs, and $10.35 copayment for all other drugs for your tier 1 through 4 drugs for the rest of the calendar year (through December 31, 2023).

    The following applies to 2023:

    Important Message About What You Pay for Vaccines – Our plan covers most Part D vaccines at no cost to you, even if you haven’t paid your deductible. Call Member Services for more information.

    Important Message About What You Pay for Insulin – You won’t pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it’s on, even if you haven’t paid your deductible.

    Getting Help from Medicare – If you chose this plan because you were looking for insulin coverage at $35 or less a month, it is important to know that you may have other options available to you for 2023 at even lower costs because of changes to the Medicare Part D program. Contact Medicare, at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week for help comparing your options.  TTY users should call 1-877-486-2048. 

    Additional Resources to Help – Please contact our Member Services number at (800) 263-0067 for additional information. (TTY users should call 711.)  Hours are 8:00 am to 8:00 pm, seven days a week.

    You can also see the 2022 Summary of Benefits  and 2023 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 2022 Premium Summary Table for Medicare Beneficiaries who get “Extra Help”  and the 2023 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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