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How does my plan's prescription drug coverage work?

Who is this for?

Learn more about your Medicare Plus Blue PPO plan.

If you're a Medicare Plus Blue℠ PPO member, this information will tell you how to use your pharmacy coverage when you need a prescription.

If you purchase your own insurance and you have a Medicare Plus Blue PPO plan, you have Part D prescription drug coverage. It's included in your monthly payment and your benefits.

Filling a prescription with a Medicare Plus Blue PPO plan works pretty much like traditional health insurance. But there are some differences. We'll help you understand how your drug coverage works to avoid surprises when it comes time to pay.

Tip: Is your Medicare Plus Blue PPO plan provided by an employer or group? Your drug coverage could work differently. If you don't know what drug coverage you have, ask your employer or group.

What you'll pay

The cost of your prescription depends on these things:

  • What plan you have: Medicare Plus Blue PPO Essential, Vitality, Signature or Assure.
  • What Medicare Part D coverage period you're in: initial coverage, coverage gap or catastrophic coverage.
  • What tier your prescription is in.
  • Where and how you fill the prescription.

Here's an example of how all that works.

Grace has Medicare Plus Blue PPO Vitality. Her doctor just prescribed the first medication she's needed this year.

Her doctor wants her to take alendronate sodium—you might know it by its brand name, Fosamax—for osteoporosis. Grace looks it up in her plan's drug list. The good news is alendronate sodium is a Tier 1 preferred generic drug, the least expensive.

Grace moved recently, so she stops by her local pharmacy to make sure they take her plan. She also asks about the price of her medication. It'll cost her around $60 a month. She gives them her prescription and her Medicare Plus Blue PPO ID card.

Grace has a $320 pharmacy deductible with her plan. So she'll have to pay the full price for her medication until she's reached $320. Then, because she's in the initial coverage period, her plan will pay 75 percent of the cost and she'll pay 25 percent. Grace's portion is called coinsurance. That'll lower the cost of her prescription to about $15 a month. She'll pay that for the rest of the year. If she doesn't need any other medications, the total cost of her prescription—12 x $60—won't reach $2,960 to put her in the coverage gap.

Important things to know

Grace took some smart steps to avoid surprises at the pharmacy.

  • First, she made sure her medication was on her plan's drug list. Learn more about drug lists.
  • Then she found out what tier it was in, which helped her know how much she would have to pay. Learn more about drug tiers.
  • Grace didn't stop there: she also reviewed the rules of her plan for pharmacy coverage, so she knew in advance about the deductible. You can use your plan's Evidence of Coverage to do the same.
  • Next, she checked that the pharmacy accepts her plan. That's another way of saying she found a pharmacy in her plan's network and it's important. In most cases, if you go to an out-of-network pharmacy your plan won't cover the cost of your prescription. It's easy to find a pharmacy in your network with Medicare Plus Blue PPO; 98 percent of pharmacies in Michigan accept your plan. Learn more about finding a pharmacy in your network.

Convenience and savings

Once you know the basics of getting your prescription filled, your plan has additional options that save you money and time, such as:

  • Although Grace went to her local pharmacy, you can also get prescriptions delivered to your door through Express Scripts® or Walgreens, our mail order pharmacies.
  • You may be able to get a 90-day refill of your prescription, reducing the number of times you have to order your medication or stop by the pharmacy.
  • If you have Medicare Plus Blue PPO Signature or Assure, you can also save money on 90-day refills. When you use mail order or go to a preferred pharmacy, you'll get a discount on copays.

Do you travel outside of Michigan for business or vacation? Medicare Plus Blue PPO has you covered. You can use any pharmacy in the Express Scripts network. Most chain pharmacies are in this network. But if you have to go to an independent pharmacy, just show them your Blues ID card and ask if you’re covered. Learn more by reading How can I get my prescription filled when traveling?

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Page Last Updated Wed Feb 25 12:34:49 EST 2015