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Medicare Prescription Drug Coverage and Pharmacies
CareAdvantage (HMO) includes the Medicare Part D prescription drug benefit, which gives you comprehensive drug coverage. It covers brand-name and generic drugs.
Covered Drugs
Covered drugs are listed in the CareAdvantage Formulary.
Coverage requirements and limits
Some drugs may have quantity limits or step therapy rules, or they may require prior authorization from CareAdvantage before they will be covered.
Low Income Subsidy
Members who qualify for CareAdvantage (HMO) have Medicare and Full-Scope Medi-Cal. By qualifying for Medi-Cal, you also qualify for
"Extra Help" with your Prescription Drug Coverage through Medicare Part D.
This "Extra Help" is also called the Low Income Subsidy.
For more information on how to apply for the Low Income Subsidy click on the following link.
Social Security Online - Prescription Drug Costs
Qualifying for this subsidy means you have no Part D premium under CareAdvantage (HMO), and you have the following co-pays for drugs:
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Year |
2010 |
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Deductible
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You Pay $0
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Generic (Tier 1) Co-pay until your Total Drug Spending* is $2,660
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You Pay $0
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Brand (Tier 2) Co-pay until your Total Drug Spending* is $2, 660
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You pay $3.30 or 6.30 depending on your income
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Generic (Tier 1) Co-pay when your Total Drug Spending* is from $2,660 to $6,440
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You pay $1.10 or $2.50, depending on your income
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Brand (Tier 2) Co-pay when your Total Drug Spending* is from $2, 660 to $6,440
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You pay $3.30 or $6.30, depending on your income
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Catastrophic coverage limit
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After your Total Drug Spending* reaches $6,440, you pay $0 for your prescription drugs.
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Members of CareAdvantage (HMO) receive this information in an attachment to their Evidence of Coverage, called the Low Income Subsidy Rider
upon enrollment and each following year.
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"Some members qualify for $0 co-payments all year, if they are in a Skilled Nursing Facility (SNF). If you feel you qualify for a lower cost-sharing
amount for generic or brand drugs, you may submit evidence of your Medi-Cal or SNF status by contacting our CareAdvantage Unit.
For more information, click on the link below."
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Center for Medicare and Medicad Services - Best Available Evidence
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Starting your Medicare Part D prescription coverage
If you are new to CareAdvantage, you may be taking a drug that is not on our formulary or has other coverage restrictions.
You may be able to get your prescription through
HPSM’s Transition Process. This describes what to do if you receive a letter that says your prescription cannot be covered. Read about the steps
for requesting exceptions, coverage determinations, and appeals.
Use Network Pharmacies for Covered Prescriptions
There are over 200 independent and chain pharmacies in the HPSM provider network located in San Mateo County and San Francisco.
CareAdvantage will also cover prescriptions filled at national network pharmacies outside of the local area. Prescriptions filled
at out-of-network pharmacies will be covered only in situations where a network pharmacy is not available to you.
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