PHP, California

Rachel Sakai
AHF Provider

Part D Prescription Drug Coverage and Costs

Members of PHP (HMO SNP) are subject to drug payment stages shown in the tables below.

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” for information about the plan’s premium.   You must continue to pay your Medicare Part B 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).  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).)

If you receive “Extra Help” (low income subsidy) from Medicare to help pay for your prescription drugs, read further below for cost sharing information specific to your level of “Extra Help.”

Some people automatically qualify for “Extra Help” and don’t need to apply. Medicare mails a letter to people who automatically qualify for “Extra Help.” People with limited income and resources may qualify for “Extra Help.” You may be able to get “Extra Help” to pay for your prescription drug premiums and costs. To see if you qualify for getting “Extra Help,” call:

  • 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day, 7 days a week;
  • The Social Security Office at 1-800-772-1213, between 7 a.m. to 7 p.m., Monday through Friday. TTY users should call 1-800-325-0778; or
  • Your State Medicaid Office.

2018 Cost-Sharing for Members Who Do Not Receive “Extra Help”

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, the plan pays its share of the cost of your drugs and you pay 25% coinsurance for all covered drugs tiers 1 through 4.

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. This amount and rules for counting costs toward this amount have been set by Medicare.

During this stage, you pay the greater of 5% coinsurance or $3.35 copayment for generic and multisource brand drugs, and $8.35 copayment for all other drugs for the rest of the calendar year (through December 31, 2018).

 

For 2018, every drug in the formulary is in one of four cost-sharing tiers show below.

Tier

One-Month Supply

Three-Month Supply

Tier 1 (Generic) 25% of the Cost 25% of the Cost
Tier 2 (Preferred Brand) 25% of the Cost 25% of the Cost
Tier 3 (Non-Preferred Brand) 25% of the Cost Not Offered
Tier 4 (Specialty Tier) 25% of the Cost Not Offered

 

If you get “Extra Help” (low income subsidy [LIS]) from Medicare, the cost-sharing tables below apply to you. If you qualify for LIS level 1, 2, or 3, the table immediately below applies. If you qualify for LIS level 4, the bottom table applies to you. The amount you pay for your prescription drugs depends on the level of LIS for which the Social Security Administration determines you qualify.

PHP will tell you prior to beginning of the plan year or when you join the plan what your cost-sharing amounts are with LIS for the year. We will also tell you if your LIS is changing.

 

2018 Cost-Sharing for Members with LIS Levels 1, 2 or 3

Stage 1
Yearly Deductible Stage

Stage 2
Initial Coverage Stage

Stage 3
Coverage Gap Stage

Stage 4
Catastrophic Coverage
Stage

This stage does not apply to you. There is no deductible for LIS levels 1, 2, or 3. You begin in this payment stage when you fill your first prescription of the
year. During this stage, the plan pays its share of the cost of your drugs
and you pay:

  • Level 1: $3.35 copayment for generic and multisource brand
    drugs, and $8.35 copayment for all other drugs
  • Level 2: $1.25 copayment for generic and multisource brand
    drugs, and $3.70 copayment for all other drugs
  • Level 3: $0 copayment for all drugs

You stay in this stage until your year-to-date “out-of-pocket costs” (the amount you and Medicare pay (as “Extra Help”)) reach a total of $5,000, and then you move to Stage 4.

This stage does not apply to you. During this stage, you pay $0 copayment for all drugs for the rest of the calendar
year (through December 31, 2018).

 

2018 Cost-Sharing for Members with LIS Level 4

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 $83 for your drugs ($83 is the amount of your deductible).

During this stage, the plan pays its share of the cost of your drugs and you pay 15% coinsurance for all covered drugs.

You stay in this stage until your year-to-date “out-of-pocket costs” (the amount you and Medicare pay (as “Extra Help”)) reach a total of $5,000, and then you move to Stage 4.

This stage does not apply to you. During this stage, you pay $3.35 copayment for generic and multisource brand drugs, and $8.35 copayment for all other drugs for the rest of the calendar year (through December 31, 2018).

 

The formulary may change at any time.  You will receive notice when necessary.  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 co-payments/coinsurance may change on January 1 of each year.


You will need the Adobe Acrobat Reader program to view the above forms. To download this free program click here or use the link above – the link will open a new window and take you to the Adobe website.

H5852_4006 2018 021418 Approved