Part D benefits are included with our Silver Plus, Platinum & Platinum Plus plans.
With Senior Health Plan (HMO), getting your prescriptions is simple. Our plans have no deductibles to meet, and no “preferred” pharmacy network to worry about.
Below are the member copays while in the Initial Coverage Limit*:
| 30 Day Supply | Silver Plus | Platinum & Platinum Plus |
|---|---|---|
| Tier 1 - Preferred Generic | $5 | $0 |
| Tier 2 - Generic | $10 | $5 |
| Insulin Tier | You pay $35 | You pay $35 |
| Tier 3 - Preferred Brand | $40 | $40 |
| Tier 4 - Non-Preferred Brand | $95 | $95 |
| Tier 5 - Specialty Tier | 33% of the cost | 33% of the cost |
Members on a Medicare Retiree group plan may have different benefits. Check your plan year benefit grid or call Customer Service with questions. Be sure to let us know what retiree group you are with.
For 2023, this plan participates in the Part D Senior Savings Model which offers lower, stable and creditable out of pocket costs for covered insulin through the different Part D benefit coverage stages. You will pay a maximum of $35 for a 1-month supply of covered insulin during the Initial Coverage and Coverage Gap (or Donut Hole) stages of your benefit.
Important Message About What You Pay for Vaccines - Our plan covers most Part D vaccines at no cost to you. Call Customer 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.
* Part D plans have different drug stages depending on your prescription drug costs. You’ll pay the copays above while in the Initial Coverage limit. You move out of the Initial Coverage Limit when your total drug costs for the year reach $4,660. See the Summary of Benefits or the Evidence of Coverage ( Silver , Silver Plus , Platinum and Platinum Plus ) for more information about the Part D coverage stages.
Part B Rebatable Drug Coinsurance Adjustment
Effective April 1, 2023, certain Medicare Part B drugs may have a lower coinsurance than what is stated in a member’s benefit documents. Members may pay a lower coinsurance if the price of the drug is rising faster than the rate of inflation. The Centers for Medicare & Medicaid Services (CMS) makes the determination on which Part B drugs qualify for the lower coinsurance and the coinsurance adjustment amount. CMS has the right to review and change this list of drugs up to 4 times a year. The Rebatable Drug Coinsurance Adjustment will occur through an enrollee refund if the mandatory reduction occurs after claims have been processed in 2023.
Part B Insulin Cost Sharing Cap
Starting July 1, 2023, Medicare Advantage plans must cover Part B insulin for use in insulin pumps at the copayment and coinsurance cap of $35 for a one-month supply of insulin.
Search for prescription medications that promote clinically useful and cost-effective drug therapy. You can look up your prescriptions in our online formulary to see what tier level your prescriptions are in.
CommunityCare members can save money on a 100 day supply of your prescription drugs when you use mail order.
| 100 Day Supply - Mail Order | Silver Plus | Platinum & Platinum Plus |
|---|---|---|
| Tier 1 - Preferred Generic | You pay $0 | You pay $0 |
| Tier 2 - Generic | You pay $0 | You pay $0 |
| Insulin Tier | You pay $70 | You pay $70 |
| Tier 3 - Preferred Brand Name | You pay $80 | You pay $80 |
| Tier 4 - Non-Preferred Drugs | You pay $190 | You pay $190 |
| Tier 5 - Specialty Tier | You pay 33% of the cost | You pay 33% of the cost |
Choose from two convenient options. More mail order prescription information.
Senior Health Plan is pleased to make its pharmacy directory available to its members. The online directory is for your reference only.
Senior Health Plan makes every effort to maintain current and accurate pharmacy data; however, periodic changes to a pharmacy's status can occur. Please contact Customer Service at (918) 594-5323 or 1-800-642-8065 if you have questions about a pharmacy's participation with Senior Health Plan. TTY/TDD users should call 1-800-722-0353.
The participating pharmacies listed in the directory are independent contractors and are not employees of Senior Health Plan. All health care decisions are strictly the responsibility of the patient and the pharmacy.
If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our Plan. Low income subsidy premium table
For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the most effective way and also help us control drug plan costs. More information regarding our drug management programs.
CMS has created a best available evidence (BAE) policy, which requires sponsors whose plans cover Part D prescription drugs to provide access to those drugs at the correct low-income subsidy (LIS) cost-sharing level when presented with evidence of a beneficiary's LIS eligibility, even if the sponsor’s system and CMS’s system do not yet reflect that eligibility. Best Available Policy and related resources located on the CMS website.