How Prescription Advantage Works For You
For Members with Medicare
Important Note: Reductions to the current fiscal year budget for Prescription Advantage require that benefits be changed effective January 1, 2010. Prescription Advantage will no longer pay any part of the Medicare Part D plan premium for members in categories S1, S2 and S3. Members in these categories will be responsible for paying the premium invoices from their Medicare Part D plans to ensure that their Medicare Part D coverage continues. Co-payment assistance from Prescription Advantage is only available to members enrolled in a Medicare Part D drug plan or creditable coverage plan.
Medicare Prescription Drug Plan Co-payments
Prescription Advantage will provide supplemental coverage for members enrolled in Medicare prescription drug plans. Assistance with co-payments is based on annual household income. There is no separate monthly premium for Prescription Advantage membership, but members are required to pay the Part D premium amounts that their Medicare Drug Plan bills them for.
Annual Out-of-Pocket Spending Limit
Prescription Advantage provides an annual out-of-pocket spending limit. Once this limit is reached, Prescription Advantage will cover prescription drug co-payments for the remainder of the plan year.
Prescription Advantage will provide assistance only for drugs covered by a member's Medicare prescription drug plan. However, Prescription Advantage will cover benzodiazepines for members, but will not cover other drugs excluded from Medicare coverage, such as barbiturates and over the counter drugs.
The Prescription Advantage plan year runs from January 1 - December 31 of each year.
For members who reach their annual out-of-pocket spending limit, Prescription Advantage covers drug co-payments for the rest of the plan year.
Please download the schedule guide for more information:
- Prescription Advantage Rate Schedule Guide for Members Eligible for Medicare - Effective April 1, 2014
For more information on how Prescription Advantage will work with Medicare prescription drug plans, see "How Prescription Advantage Works with Medicare's Prescription Drug Coverage (Part D)".
For Members with Creditable Coverage
For members enrolled in creditable coverage plans, coverage that is equal to or better than Medicare prescription drug coverage, Prescription Advantage may provide assistance with plan co-payments. Members in creditable coverage plans are responsible for their plan's monthly premiums. There is no separate monthly premium for Prescription Advantage membership.
For Members Not Eligible for Medicare
Deductible and Co-payments
Deductible and co-payments are based on annual household income. There is no monthly premium for Prescription Advantage membership. When you purchase prescription drugs, you first satisfy your deductible, then you pay a modest co-payment. Some members may qualify to have part or all of their deductibles waived, depending on their annual household income.
Annual Out-of-Pocket Spending Limit
Prescription Advantage provides an annual out-of-pocket spending limit. Once the amount you have paid in deductible and co-payments reaches your annual out-of-pocket spending limit, Prescription Advantage will cover prescription drug co-payments for drugs that are on the plan formulary for the remainder of the plan year.
The Prescription Advantage formulary, for members not eligible for Medicare, includes most prescription drugs.
The formulary for non-Medicare members in Prescription Advantage categorizes prescription drugs into three categories: generic drugs, brand-name drugs, and additional brand-name drugs. Generic drugs have the lowest co-payment, while additional brand-name drugs have the highest co-payment. The Plan's formulary covers most outpatient oral prescription drugs, including insulin and disposable insulin syringes with needles.
The Prescription Advantage plan year runs from January 1 - December 31 of each year. For members who reach their annual out-of-pocket spending limit, Prescription Advantage pays the full cost of their covered prescription drugs through the end of the plan year.
Please read Prescription Advantage Rate Schedule Guide for Members Not Eligible for Medicare (PDF) for more information.
Medmetrics Health Partners
Effective July 1, 2006, all Prescription Advantage members will have their prescription drug claims processed through Medmetrics Health Partners.
Also starting July 1 st, Walgreen's Mail Service will be the new prescription drug mail service provider for Prescription Advantage. Please read Mail Order Prescriptions: What You Need To Do for more information on mail order through Walgreens Mail Service.
Please note: The legislation which funds Prescription Advantage requires the Executive Office of Elder Affairs to operate the program within its appropriation for the current fiscal year; thus, during the course of the year, the Plan may be required to impose cost containment measures.
For More Information
Call 1-800-AGE-INFO (1-800-243-4636)
Customer Service Representatives are available to answer your questions Monday-Friday, 9 AM - 5 PM EST