Changing the way you
receive healthcare

Prescription Drug Coverage and Costs

  • Changes to Part D Prescription Drug Coverage 

    PHP (HMO SNP) has made some changes to its Formulary (Drug List), including changes to the drugs we cover and changes to the restrictions that apply to our coverage for certain drugs. Review the following publications to make sure your drugs will be covered next year and to see if there will be any restrictions. If you are affected by a change in drug coverage for 2023, please review our Formulary page for actions you can take.

    Changes to Part D Prescription Drug Costs

    For 2023, members of PHP are subject to drug payment stages shown in the tables below. PHP has no Part D premium in 2023. You must continue to pay your Medicare Part B premium.

    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.

    2023 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 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.

    For 2023, every drug in the formulary is in one of four cost-sharing tiers show below.

    TierOne-Month Supply
    (30 Days)
    Three-Month Supply
    (100 Days)
    Tier 1 (Generic Drugs)15% of the Cost15% of the Cost
    Tier 2 (Preferred Brand Drugs)15% of the Cost15% of the Cost
    Tier 3 (Non-Preferred Brand Drugs)25% of the Cost25% of the Cost
    Tier 4 (Specialty Drugs)25% of the Cost25% of the Cost
    Tier 5 (Select Care Drugs)No CostNo Cost

    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.

    2023 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 the following for tier 1 through 4 drugs:

    • Level 1: $4.15 copayment for generic and multisource brand
      drugs, and $10.35 copayment for all other drugs
    • Level 2: $1.45 copayment for generic and multisource brand
      drugs, and $4.30 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 $7,400, 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, 2023).

    2023 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 tier 1 through 4 drugs.

    You stay in this stage until you have paid $104 for your drugs ($104 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 covered drugs in tiers 1 through 4.

    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 $7,400, and then you move to Stage 4.

    This stage does not apply to you.During this stage, you pay $4.15 copayment for generic and multisource brand drugs, and $10.35 copayment for all other drugs for tier 1 through 4 drugs the rest of the calendar year (through December 31, 2023).
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