HealthChoice High and Low Option plans without Part D

HealthChoice Medicare supplement plans without Part D include creditable prescription drug coverage but not Part D coverage. These plans were specifically designed for members who:

Already have Medicare Part D coverage through another plan or employer.
Receive a subsidy for prescription drug benefits from their or their spouse’s employer.
Receive VA benefits for prescription drugs but desire to maintain additional prescription coverage for medications not covered by the VA.
Did not enroll in Part D coverage timely or at all and must wait for a Part D enrollment period or the next annual Option Period to enroll.

Note: Premiums for these plans are higher because HealthChoice does not receive a prescription drug subsidy from Medicare for members enrolled in these plans.

Pharmacy copay structure for network benefits

Prescription medications	30-day supply	90-day supply
Generic (Tier 1) drugs	Up to $10 copay	Up to $25 copay
Preferred (Tier 2) drugs	Up to $45 copay	Up to $90 copay
Non-preferred (Tier 3) drugs	Up to $75 copay	Up to $150 copay
Specialty (Tier 4) drugs	Generic – $10 copay Preferred – $100 copay Non-Preferred – $200 copay	30-day copay applies to each 30-day supply
Preferred tobacco cessation	$0 copay	$0 copay
Insulin	Up to $30 copay. Copay is applied before the deductible.	Up to $90 copay. Copay is applied before the deductible.
Vaccinations	$0 copay	$0 copay
Pharmacy out-of-pocket maximum The annual out-of-pocket maximum is $2,000. Only your copays for covered prescription drugs purchased at network pharmacies count toward the out-of-pocket maximum. Once you reach the pharmacy out-of-pocket maximum, you pay $0 for covered prescription drugs purchased at network pharmacies for the remainder of the calendar year.

Pharmacy benefits generally cover up to a 30- or 90-day supply. Specific therapeutic categories, drugs and/or dosage forms may have more restrictive quantity and/or duration of therapy limitations.
Some drugs require prior authorization.

Pharmacy deductible	Standard coverage	Catastrophic Coverage	Insulin
You pay the first $590 in drug costs.	After the deductible, you and HealthChoice share prescription drug costs. You pay 25% and HealthChoice pays 75% until total drug spending reaches $2,000.	After you spend $2,000 out of pocket, you pay $0 for covered prescription drugs for the remainder of the calendar year.	You pay up to $30 copay per 30-day supply and up to $90 copay per 31- to 90-day supply. Copay is applied before the deductible.

Pharmacy benefits generally cover up to a 30- or 90-day supply. Specific therapeutic categories, drugs and/or dosage forms may have more restrictive quantity and/or duration of therapy limitations.
Some drugs require prior authorization.