Medicare Prescription Drug Plan

Medicare members pay the applicable copayment or the cost of the drug, whichever is less, in the Initial Coverage and Coverage Gap Stage. There are certain medications that MCHCP covers at 100%¹, when accompanied by a prescription and filled at an Express Scripts Medicare network pharmacy. For more information, see Preventive Services.

Description	Tier	Home Delivery three-month (90-day) supply	Retail one-month (31-day) supply	Retail two-month (60-day) supply	Retail three-month (90-day) supply
Initial Coverage Stage	Tier 1 Preferred Generic drugs	Home Delivery (90-day supply) — $25 copayment	Retail (31-day supply) — $10 copayment	Retail (60-day supply) — $20 copayment	Retail (90-day supply) — $30 copayment
	Tier 2 Preferred drugs	Home Delivery (90-day supply) — $100 copayment	Retail (31-day supply) — $40 copayment	Retail (60-day supply) — $80 copayment	Retail (90-day supply) — $120 copayment
	Tier 3 Non-preferred drugs	Home Delivery (90-day supply) — $250 copayment	Retail (31-day supply) — $100 copayment	Retail (60-day supply) — $200 copayment	Retail (90-day supply) — $300 copayment
Coverage Gap Stage (Donut Hole)	After annual drug costs reach $5,030 members will continue to pay the same cost-sharing amount as in the Initial Coverage stage until annual out-of-pocket drug costs reach $8,000.
Catastrophic Coverage Stage	After annual out-of-pocket drug costs reach $8,000 members will have $0 cost-share.

Drugs covered at 100% (Generic or Preferred 100 percent, Non-Preferred $100 copayment) are those described in the United States Preventive Services Task Force A and B recommendations, the Advisory Committee on Immunization Practices (ACIP) of the CDC, and HRSA Guidelines for women, as well as children, including the American Academy of Pediatrics Bright Futures periodicity guidelines.

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