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	Specialty drugs are available in only a 30-day supply
Preferred (Tier 5) tobacco cessation drugs	$0 copay	$0 copay
Pharmacy out-of-pocket maximum The annual out-of-pocket maximum is $6,550. 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.

No coverage gap.
Pharmacy benefits generally cover up to a 30- or 90-day supply. Specific therapeutic categories, medications and/or dosage forms may have more restrictive quantity and/or duration of therapy limitations.
Some medications require prior authorization.

Pharmacy deductible	Initial coverage limit	Coverage gap	Catastrophic coverage
You pay the first $445 in drug costs.	After the deductible, you and HealthChoice share prescription drug costs. You pay 25% ($921.25) and HealthChoice pays 75% ($2,763.75) until total drug spending reaches $4,130.	You pay 100% of coverage costs until you meet the catastrophic coverage threshold.	After you spend $6,550 out-of-pocket, you pay $0 for covered prescription drugs for the remainder of the calendar year.

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

SilverScript High – Evidence of Coverage

SilverScript Low – Evidence of Coverage