To view and print PDF documents on this website, download the latest version of Adobe Reader for free.
Essence Washington Part D Medicare Prescription Drug Plan
2008 Paying for Drugs
If you qualify for extra help with your drug costs, your costs for your drugs may be different than those described below. See Extra Help on this website.
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., initial coverage 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 and your drug costs for each coverage level are described below.
Initial Coverage Period
During the initial coverage period, we will pay part of the costs for your covered drugs and you will pay the other part. The amount you pay when you fill a covered prescription is called the "co-payment or co-insurance". Your co-payment/co-insurance will vary depending on the drug and where the prescription is filled.
Standard Plan
| Drug Tier | Retail Co-payment/ Co-insurance (31-day supply) |
Retail Co-payment/ Co-insurance (93-day supply) |
Mail-Order Co-payment/ Co-insurance (31-day supply) |
Mail-Order Co-payment/ Co-insurance (93-day supply) |
|---|---|---|---|---|
| Tier 1 Generic | $5.00 | $15.00 | $5.00 | $15.00 |
| Tier 2 Preferred Brand | $29.00 | $87.00 | $29.00 | $87.00 |
| Tier 3 Non-Preferred Brand | $59.00 | $177.00 | $59.00 | $177.00 |
| Tier 4 Injectible | 20% | 20% | 20% | 20% |
Enhanced Plan
| Drug Tier | Retail Co-payment/ Co-insurance (31-day supply) |
Retail Co-payment/ Co-insurance (93-day supply) |
Mail-Order Co-payment/ Co-insurance (31-day supply) |
Mail-Order Co-payment/ Co-insurance (93-day supply) |
|---|---|---|---|---|
| Tier 1 Generic | $5.00 | $15.00 | $5.00 | $15.00 |
| Tier 2 Preferred Brand | $29.00 | $87.00 | $29.00 | $87.00 |
| Tier 3 Non-Preferred Brand | $59.00 | $150.00 | $50.00 | $150.00 |
| Tier 4 Injectible | 20% | 20% | 20% | 20% |
Once your total drug costs reach $3,000, you will reach your initial coverage limit. Your initial coverage limit is calculated by adding payments made by this Plan and you. If other individuals, organizations, current or former employer/union, and another insurance plan or policy help pay for your drugs under this plan, the amount they spend may count towards your initial coverage limit.
Coverage after you reach your Initial Coverage Limit and before you qualify for Catastrophic Coverage:
Standard Plan
After your total drug costs reach $3,000, you or others on your behalf, will pay 100% for your drugs until your total out-of-pocket costs reach $4,050 and you qualify for Catastrophic Coverage.
Enhanced Plan
After your total drug costs reach $3,000, we will continue to provide prescription drug coverage, for generic drugs only, until your total out-of-pocket costs reach $4,050. You or others on your behalf, will pay the set co-payments and co-insurance amount. (You pay 100% for brand-name drugs.) Once your total out-of-pocket costs reach $4,050, you will qualify for Catastrophic Coverage.
Catastrophic Coverage
All Medicare Prescription Drug Plans include catastrophic coverage for people with high drug costs. In order to qualify for catastrophic coverage, you must spend $4,050 out-of-pocket for the year. When the total amount you have paid toward co-payments, and the cost for covered Part D drugs after you reach the initial coverage limit reaches $4,050, you will qualify for catastrophic coverage. During catastrophic coverage you will pay the greater of $2.25 for generics, and $5.60 for all other drugs, or 5% co-insurance. We will pay the rest.
Note: If you qualify for a special low income subsidy for which you apply through the Social Security Administration, your direct out-of-pocket amounts and what goes towards your True Out-of-Pocket (TROOP) expenses will be different from what is described above.
How is Your TrOOP Calculated?
The following types of payments for prescription drugs can count toward your true out-of-pocket costs and help you qualify for catastrophic coverage so long as the drug you are paying for is a Part D drug, is on the formulary, is obtained at a network pharmacy, and otherwise meets our coverage requirements:
- Your co-insurance or co-payments
When you have spent a total of $4,050 for these items, you will reach the catastrophic coverage level.
Purchases that will not count toward your true out-of-pocket costs include:
- Prescription drugs purchased outside the United States and its territories;
- Prescription drugs not covered by the Plan.