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Prescription Drug Benefit

AgeRight Advantage Health Plan (HMO I-SNP) provides Medicare Part D prescription drug coverage through its partner Navitus Health Solutions.

Navitus Health Solutions is a full-service pharmacy benefit management company committed to lowering drug costs, improving health, and providing superior customer service in a manner that instills trust and confidence. Together, we make it easier for you to follow your doctor’s orders related to your health care and prescription drug use.

For your convenience, there is a complete list of all covered drugs in the plan (a comprehensive formulary). Our Online Formulary lists the Part D drugs covered by AgeRight Advantage. Our formulary is designed to cover the drugs most needed to treat the special needs of our Members.

If the drug you are taking is not on the list of covered drugs, read your Prescription Drug Transition Policy and Evidence of Coverage to find out what you can do. This includes instructions for both new and current Members.

If you would like help managing your prescription drugs, read about our Medication Therapy Management program and its eligibility requirements.

Need to find a participating pharmacy near you? Click here to search our Pharmacy Directory.

Member Part D Prescription Drug Benefits

Below is a brief summary of benefits. For a complete list of benefits and other resources, please review your Evidence of Coverage.

How much do I pay?

For Part B drugs such as chemotherapy drugs: 25% of the cost
Other Part B drugs: 25% of the cost

Initial Coverage?

After you pay your yearly deductible, you pay 25% of the cost for all drugs covered by this plan until your total yearly drug costs reach $4,130. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.

You may get your drugs at network retail pharmacies.

If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy

Coverage Gap

Most Medicare drug plans have a coverage gap (also called the “donut hole”). This means that there’s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $4,130.

After you enter the coverage gap, you pay 25% of the plan’s cost for covered brand name drugs and 37% of the plan’s cost for covered generic drugs until your costs total $6,550, which is the end of the coverage gap. Not everyone will enter the coverage gap.

Catastrophic Coverage

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $6,550, you pay the greater of:

  • 5% of the cost, or
  • $3.70 copay for generic (including brand drugs treated as generic) and a $9.20 copayment for all other drugs.

If you have questions or want to request additional information, please call Member Services at 1-844-854-6885 (TTY 711). Calls to this number are free.

How to Request a Coverage Determination

What Is a Coverage Determination?

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What Is an Exception?

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Who Can Request a Coverage Determination / Exception?

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When Can a Coverage Determination/ Exception Be Requested?

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Important Things to Know About Asking for Exceptions

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Where Can a Coverage Determination/Exception Be Filed?

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Request Forms for Prescription Drugs

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Best Available Evidence Policy

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Member Materials

Medicare Prescription Drug Forms

Important Documents

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