Prescription Drug Coverage and Coverage Gap
As a member of the Choices Select (HMO-POS) plan, you receive Medicare Part D prescription drug coverage. Each year, your prescription drug coverage runs through a cycle, beginning on January 1.
There are three stages to the prescription drug coverage cycle. These stages are the initial coverage stage (standard coverage), the coverage gap stage and the catastrophic coverage stage.
Below are descriptions of each of these three stages of the drug coverage cycle for 2010. The picture at the bottom of the page references the corresponding stage numbers.
Stage 1: Initial Coverage Gap
During this stage, you pay your standard costs (called “copays”) for your prescription drugs, and Peoples Health pays the rest of the costs for your drugs. Please reference your Evidence of Coverage to determine what these costs are. You pay these costs until your total drug costs—which includes your total out-of-pocket costs and the costs Peoples Health pays—reach $2,830*. Once your drug costs reach this amount, you move on to the Coverage Gap Stage.
Stage 2: Coverage Gap StageDuring this stage, you pay 100 percent of the costs for all brand-name drugs and specialty drugs. Reference the Peoples Health
online formulary to determine if your drugs fall into either of these categories.
Remember: Peoples Health still covers generic drugs in the coverage gap. This means you will still pay your standard costs for these drugs. The coverage gap ends when
your total out-of-pocket costs—which includes the out-of-pocket costs you paid in Stage 1—reach $4,550*. Once your drug costs reach this amount, you move on to the Catastrophic Coverage Stage.
Stage 3: Catastrophic Coverage Stage
During this stage, you pay reduced copays for your prescription drugs. You will pay which ever is greater of the following:
· 5 percent of the total cost of your drugs, OR
· $2.50 for generic drugs or drugs treated like generics, and $6.30 for all other drugs
Peoples Health pays the rest of your drug costs. The prescription drug cycle starts over again on January 1 of every year.
*These amounts reflect the drug coverage cycle for 2010.
Important: Please note that not all drugs Peoples Health covers on our formulary (our list of covered drugs) count toward your total Medicare Part D costs. Some drugs that Peoples Health covers on its formulary are not normally covered by Medicare Part D. Only Medicare Part D-covered drugs will count toward your total drug costs. To find out whether your drug is covered by Medicare Part D and will count toward your total drug costs, you should contact Peoples Health Member Services at (800) 631-8843, ext. 2, Monday through Friday, from 8 a.m. to 8 p.m., before you fill your prescription. Telephone device for the hearing impaired users may call (888) 631-9979.