Medicare Part D (Prescription Drug Coverage) is the part of the Medicare program designed to help cover cost of prescription drugs, lower costs of both brand-name and generic drugs as well as help protect against higher costs.
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Unlike Original Medicare (Medicare Parts A and B), Medicare Part D prescription drug coverage is administered by private companies. You have to sign up for coverage with a Medicare-approved Part D plan in order to receive benefits.
Without coverage, many people may not be able to afford the monthly bill for their needed drugs. And without coverage, there is no limit to the amount you may pay in a year for prescriptions.
There are two ways you can get Medicare Part D coverage:
The first is to sign up for a stand-alone Part D plan. This means that you may pay a monthly premium to a Part D plan in addition to any premiums you pay for your medical coverage and your Part B premium each month.
The second way is to enroll in a Medicare Advantage plan that includes Part D coverage. All plans from Memorial Hermann Medicare Advantage HMO are Medicare Advantage plans that include prescription drug coverage. You get all of your Part A, Part B and Part D prescription coverage with just one identification card. Find out how much you may be able to save on prescription drugs that you take with our Memorial Hermann Advantage plans. Speak with a Memorial Hermann Advantage Advisor today at (866) 350-2715. (TTY 711)
There are 4 official stages of Part D prescription coverage as designed by the Center for Medicare and Medicaid Services (CMS). When a member fills a prescription, their coverage stage is determined by certain dollar limits the plan and/or member has already paid. A member’s payment amount for that drug can change throughout the year as they go through these stages.
Stage 1: Yearly Deductible Stage – During this stage, members pay the full cost of Tier 4 and Tier 5 drugs. This stage ends when the total amount of Tier 4 and Tier 5 drugs have reached the $300 deductible.
Stage 2: Initial Coverage Stage – Members pay their share of the drug cost through a copay or coinsurance for Tier 1, Tier 2, Tier 3, Tier 4, Tier 5 and Tier 6 drugs. This stage ends when year-to-date total drug costs (your payment plus any plan’s payment) total $4,430.
Stage 3: Coverage Gap Stage (the Part D “Donut Hole”) — Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means there's a temporary limit on what the drug plan will cover for drugs. Not everyone will enter the coverage gap.
The donut hole begins after you have met your plan deductible and have spent a certain amount for covered drugs. This amount is $4,430 in 2022. After you and your plan have reached this limit, you pay 25% of the medication's cost for covered brand-name prescription drugs and 25% of the price for generic drugs. This stage ends when you have spent $7,050 in out-of-pocket costs on prescription drugs in 2022.
Stage 4: Catastrophic Coverage Stage - After your total yearly drug costs reach $7,050 in 2022, you enter the catastrophic coverage phase and will pay either 5% of the cost for each of your drugs (coinsurance), or $3.95 for generic drugs and $9.85 for brand-name drugs (whichever is greater) for the rest of the plan year, which ends on 12/31/2022. See your Summary of Benefits for more details.
To help you navigate your prescription coverage and benefits, you may visit our pharmacy benefits page.
Like Medicare Part D prescription drug plans and Medicare Advantage plans that include Part D coverage, pharmacy networks are involved. If you have an HMO plan, this means that you may be required to go to a network pharmacy. You may also have access to a mail order pharmacy, which may lower your prescription costs if you order several months at a time. You may view our network information and see our preferred pharmacies by going to the pharmacy directory page.
Memorial Hermann Advantage HMO plans are designed to be easy to use where you live or work, so there are convenient pharmacy locations throughout the Greater Houston Area.
Most plans also use a formulary or drug list. This lists all of the prescription drugs covered by the plan. Within the formulary, some drugs may cost more depending on if they are brand name or if the drug company charges more for that specific drug. Drugs are categorized within the formulary by how much they cost. This is called a tier system. To learn more about the Memorial Hermann Advantage HMO’s Medicare Prescription coverage and benefits, please visit our pharmacy formulary page.
If you have additional questions or want to learn more, you may call our Customer Service team today at (855) 645-8448 (TTY 711) 8 a.m. to 8 p.m. CST, 7 days a week from Oct. 1 - March 31 and 8 a.m. to 8 p.m. CST, Monday - Friday from April 1 – Sept. 30.
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