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2013 65C Plus Prescription Drug BRx (Cost)

HMSA’s 65C Plus (Cost) is closed to new members as of Jan. 1, 2011. Current 65C Plus members can remain in 65C Plus in 2013, unless they choose to leave the plan. HMSA is offering Akamai Advantage for an effective date of Jan. 1, 2013.

HMSA’s 65C Plus Basic Prescription Drug Coverage (Cost), BRx, is an optional supplemental benefit for members of HMSA’s 65C Plus Basic Option (Cost) health plan.

HMSA’s 65C Plus Prescription Drug Coverage (Cost) helps you manage your prescription costs and protect against higher costs in the future.

  • Statewide network of over 200 contracting retail pharmacies.
  • Mail-order service is available for your convenience and savings.
  • 65C Plus Prescription Drug Coverage (Cost) has contracts with pharmacies that equal or exceed CMS requirements for pharmacy access in the state of Hawaii.

Online tools can help you manage your medications and make the most of your prescription drug benefits. Find out if your drug is covered on HMSA’s formulary, find available alternatives, and monitor your benefit status in relation to the Medicare Part D coverage gap (also called the "doughnut hole") through the Drug Comparison Tool . Log on to My Account to:

  • Find out if there are lower-cost alternatives to the medications you’re currently taking.
  • See a list of all your prescriptions and how much you’ve spent on medications.
  • See the possible side effects and adverse reactions of medications.
  • Ask registered pharmacists questions 24 hours a day.
  • Order prescriptions and refills online and have them delivered to your home.

How Much do You Pay for Drugs Covered by this Plan?

When you fill a prescription for a covered drug, you may pay part of the costs for your drug. The amount you pay for your drug depends on what coverage level you are in (i.e., deductible, initial coverage period, the period after you reach your initial coverage limit, and catastrophic level), the type of drug it is, and whether you are filling your prescription at an in-network or out-of-network pharmacy. Each phase of the benefit is described below.

This page reflects in-network copayments. If you obtain prescription drugs from out-of-netwok pharmacies, you may have to pay higher copayments/coinsurance than shown here. See this plan’s Evidence of Coverage for specific copayments or coinsurance.

Deductible

You will pay a yearly deductible of $325. After you meet the deductible, you will reach the initial coverage period.

Initial Coverage Period

During the initial coverage period, HMSA will pay part of the costs for your covered drugs and you will pay the other part in the form of a copayment or coinsurance. The amount you pay will vary depending on the drug and where the prescription is filled.

Once your total drug costs reach $2,970, you will reach your initial coverage limit. Your initial coverage limit is calculated by adding payments made by you and HMSA.

During Initial Coverage Period, you pay:

For a 30-day Supply From a Network Pharmacy

  • Tier 1 / Generic $6
  • Tier 2 / Preferred Brand $45
  • Tier 3 / Non-Preferred Brand $70
  • Tier 4 / Specialty 25%

For a 90-Day Supply Through Mail-Order

  • Tier 1 / Generic $12
  • Tier 2 / Preferred Brand $90
  • Tier 3 / Non-Preferred Brand $140
  • Tier 4 / Specialty Drugs Not Available

Coverage Gap

After your total drug costs reach $2,970, you pay 47.5% for brand drugs or 79% for generic drugs. When your total out-of-pocket costs reach $4,750, you will qualify for catastrophic coverage.

Use the online tools at My Account to keep track of your drug costs. You’ll see a list of all your prescriptions with current totals of how much you’ve spent on medications.

Catastrophic Coverage

All Medicare Prescription Drug Plans include catastrophic coverage for people with high drug costs. To qualify for catastrophic coverage, you must spend $4,750 out-of-pocket for the year. During catastrophic coverage, you will pay a reduced copayment or coinsurance amount for your covered drugs. HMSA will pay the rest.

During the Catastrophic Coverage Period, you pay:

From a Network Pharmacy or through Mail-Order

You pay the greater of: 5% coinsurance, or $2.65 copay for generic (including brand drugs treated as generic) and a $6.60 copay for all other drugs.

Extra Help with Medicare Prescription Drug Costs

You may be able to get Extra Help with Medicare Prescription Drug costs. If eligible, Medicare could pay for 75 percent of drug costs, including monthly prescription drug premiums, annual deductibles, and coinsurance. Many people are eligible for these savings and don’t even know it.

Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty.

To see if you qualify for getting Extra Help, call:

  • 1 (800) MEDICARE [1 (800) 633-4227]. TTY users should call 1 (877) 486-2048, 24 hours a day/seven days a week;
  • The Social Security office at 1 (800) 772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call 1 (800) 325-0778; or
  • Your state Medicaid office.

Contact

Current 65C Plus Prescription Drug Coverage (Cost) members with questions about their plan may contact Customer Service from 8 a.m. to 8 p.m., seven days a week.

Oahu: (808) 948-6000
Neighbor Islands: 1 (800) 776-4672 (toll-free)

For the hearing- and speech-impaired:
TTY: 711

Plan Materials

Member Information

Appeals & Grievances

Formulary

65C Plus (Cost) has a contract with the Centers for Medicare & Medicaid Services (CMS), the government agency that runs the Medicare program. This contract renews each year. At the end of each year, the contract is reviewed, and either 65C Plus (Cost) or CMS can decide to end it. It is possible for our contract to end at some other time during the year, too. If the contract should end, HMSA will provide advance notice to all 65C Plus (Cost) members.

  • Benefits, formulary, pharmacy network, premium, and/or copayments/coinsurance may change on Jan. 1, of each year.
  • Limitations, copayments, and restrictions may apply.
  • You must use network pharmacies to access your prescription drug benefit, except under non-routine circumstances. Quantity limitations and restrictions may apply.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan.