CareAdvantage Dual Eligible Special Needs Plan (D-SNP) 2023

Drug Costs

Premiums

CareAdvantage members do not pay monthly premiums because the Medicare Part B premium is covered by the Medi-Cal program.

Co-payments

Prescription drug co-pays range from:

• $0, $1.45 or $4.15 for generic drugs
• $0, $4.30 or $10.35 for brand-name drugs

The amount of your co-pay will depend on:

• Whether you get a generic or brand-name drug
• Your income
• Whether you qualify for the Extra Help with Medicare Prescriptions Program
• How much you and HPSM have already paid in the current year for your prescriptions

There is no co-payment for:

• Drugs you receive at a nursing home facility or at a hospital
• Over-the-counter drugs covered by CareAdvantage
• Over-the-counter drugs and vitamins covered by Medi-Cal Rx

Extra Help

If you have difficulty affording co-pays

You may qualify for the Extra Help with Medicare Prescriptions Program. Depending on your income and resources, you may be eligible for $0 drug co-pays.

To apply for the Extra Help program:

• Call the Social Security Office 1-800-772-1213 TTY: 1-800-325-0778 Hours: Monday - Friday, 7:00 a.m. to 7:00 p.m.
• Call Medicare and ask for the Extra Help Program application: 1-800-MEDICARE (1-800-633-4227) TTY: 1-877-486-2048

Eligibility for the Extra Help Program

If Medicare does not have current or accurate information about your income and resources, you can present your claim to be eligible through the Best Available Evidence policy.

 By clicking on this link, you will be leaving the CareAdvantage website.

Prescription reimbursements

If you pay the full cost of a prescription, CareAdvantage will reimburse you under certain circumstances, such as when you:

• Fill a prescription in an emergency situation at a non-network pharmacy
• Need a specialized drug that is not available at a network pharmacy
• Need a drug that is only available, by law, at specific pharmacies

Note that HPSM will not reimburse you for your Part D prescription co-pay.

To request reimbursement

Prescription reimbursement requests for CareAdvantage covered drugs and items should be submitted within 1 year (365 days). To request a prescription reimbursement, send us your bill and proof of any payment you have made. (Proof of payment can be a copy of the check you wrote or a receipt from the provider.) Mail these items to:

For information regarding prescription reimbursement requests for Medi-Cal Rx covered over-the-counter drugs and vitamins, please visit the Medi-Cal Rx website (www.medi-calrx.dhcs.ca.gov). You can also call the Medi-Cal Rx Customer Service Center at 1-800-977-2273.