Use the links below to access the Platinum Comprehensive and Abridged Formularies.
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 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 2024.
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.
Enjoy the convenience of extended supplies on select Tier 1 medications (100 days or more) and pay $0 copay.
| Formulary Changes | Prior Authorization | Step Therapy | Quantity Limits | |
| January | N/A | January 2025 Prior Authorization Criteria | January 2025 Step Therapy | See comprehensive formulary for quantity limits. |
HPMS Formulary ID: 00025283 Version 8
HPMS Formulary Approval Date: 10/01/2024
Updated: 01/2025
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