Prescription Drug Coverage and Costs
Members of PHP are subject to drug payment stages shown in the tables below. PHP has no Part D premium in 2025. 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.
2025 Cost-Sharing for Members Who Do Not Receive “Extra Help”
Stage 1 | Stage 2 | Stage 3 |
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 pay nothing for drugs on tier 5. You stay in this stage until you have paid $580 for your drugs ($580 is the amount of your deductible). The deductible does not apply to covered insulin products and most adult Part D vaccines, including shingles, tetanus and travel vaccines. You pay $35 per month supply of each covered insulin product. | During this stage, you pay coinsurance for covered drugs in tiers 1 through 4 as follows:
You pay nothing for drugs on tier 5. You pay $35 per month supply of each covered insulin product. Once you have paid $2,000 out of pocket for Part D drugs, you will move to the next stage (the Catastrophic Coverage Stage). | During this payment stage, the plan pays the full cost for your covered Part D drugs. You pay nothing. |
For 2025, every drug in the formulary is in one of four cost-sharing tiers show below.
| Tier | One-Month Supply (30 Days) | Three-Month Supply (100 Days) |
| Tier 1 (Generic Drugs) | 15% of the Cost | 15% of the Cost |
| Tier 2 (Preferred Brand Drugs) | 15% of the Cost | 15% of the Cost |
| Tier 3 (Non-Preferred Brand Drugs) | 25% of the Cost | 25% of the Cost |
| Tier 4 (Specialty Drugs) | 25% of the Cost | 25% of the Cost |
| Tier 5 (Select Care Drugs) | No Cost | No 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. 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.
2025 Cost-Sharing for Members with LIS Levels 1, 2 or 3
Stage 1 | Stage 2 | Stage 3 |
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
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 $2,000, and then you move to Stage 3. | During this stage, you pay nothing for all covered drugs for the rest of the calendar year (through December 31, 2025). |
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