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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.

Medicare Supplement Plan handbook

Comprehensive Formulary (Without Part D Plans)

Last Modified on Nov 03, 2021
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