2020 Prescription Drug Benefits2019-10-04T09:08:30-04:00

Nevada (Carson City, Douglas, Lyon, Storey and Washoe counties)

Standard Retail Cost-Sharing — 30-day Supply

Prominence Plus Plan
Prescription Drug Deductible No Deductible
Phase 1: Initial Coverage
Tier 1 (Preferred Generic)
You pay $0
Tier 2 (Generic) You pay $16
Tier 3 (Preferred Brand) You pay $40
Tier 4 (Non-Preferred Drugs) You pay $100
Tier 5 (Specialty Drugs) You pay 33%
Tier 6 (Selected Drugs) You pay $0
Phase 2: Coverage Gap Tier 1, 2 and 6 drugs are covered in the gap

Mail Order — 100-day Supply

Prominence Plus Plan
Prescription Drug Deductible No Deductible
Phase 1: Initial Coverage
Tier 1 (Preferred Generic)
You pay $0
Tier 2 (Generic) You pay $32
Tier 3 (Preferred Brand) You pay $120
Tier 4 (Non-Preferred Drugs) You pay $300
Tier 5 (Specialty Drugs) Not available
Tier 6 (Selected Drugs) You pay $0
Phase 2: Coverage Gap Tier 1, 2 and 6 drugs are covered in the gap

North Texas and Texoma (Cooke, Deaf Smith, Fannin, Gray, Grayson, Moore, Potter and Randall counties)

Standard Retail Cost-Sharing — 30-day Supply

Prominence Plus Plan
Prescription Drug Deductible No Deductible
Phase 1: Initial Coverage
Tier 1 (Preferred Generic)
You pay $0
Tier 2 (Generic) You pay $13
Tier 3 (Preferred Brand) You pay $35
Tier 4 (Non-Preferred Drugs) You pay $100
Tier 5 (Specialty Drugs) You pay 33%
Tier 6 (Selected Drugs) You pay $0
Phase 2: Coverage Gap Tier 1, 2 and 6 drugs are covered in the gap

Mail Order — 100-day Supply

Prominence Plus Plan
Prescription Drug Deductible No Deductible
Phase 1: Initial Coverage
Tier 1 (Preferred Generic)
You pay $0
Tier 2 (Generic) You pay $26
Tier 3 (Preferred Brand) You pay $105
Tier 4 (Non-Preferred Drugs) You pay $300
Tier 5 (Specialty Drugs) Not available
Tier 6 (Selected Drugs) You pay $0
Phase 2: Coverage Gap Tier 1, 2 and 6 drugs are covered in the gap

South Texas (Brooks, Hidalgo and Starr counties)

Standard Retail Cost-Sharing — 30-day Supply

Prominence Plus Plan
Prescription Drug Deductible No Deductible
Phase 1: Initial Coverage
Tier 1 (Preferred Generic)
You pay $0
Tier 2 (Generic) You pay $12
Tier 3 (Preferred Brand) You pay $35
Tier 4 (Non-Preferred Drugs) You pay $100
Tier 5 (Specialty Drugs) You pay 33%
Tier 6 (Selected Drugs) You pay $0
Phase 2: Coverage Gap Tier 1, 2 and 6 drugs are covered in the gap

Mail Order — 100-day Supply

Prominence Plus Plan
Prescription Drug Deductible No Deductible
Phase 1: Initial Coverage
Tier 1 (Preferred Generic)
You pay $0
Tier 2 (Generic) You pay $24
Tier 3 (Preferred Brand) You pay $105
Tier 4 (Non-Preferred Drugs) You pay $300
Tier 5 (Specialty Drugs) Not available
Tier 6 (Selected Drugs) You pay $0
Phase 2: Coverage Gap Tier 1, 2 and 6 drugs are covered in the gap

Cost-sharing may change if you enter another phase of the Part D benefit.

Coverage Stages — How Much Do You Pay?

Determine how much the drug will cost based on your coverage stage.

Stage 1: Initial Coverage Stage

The cost of your drugs is split between you and the plan. You stay in this stage until your payments for the year plus the plan’s payments total $4,020.

Stage 2: Coverage Gap Stage/Donut Hole

You pay 25 percent of the plan’s cost for covered brand name drugs and 25 percent of the plan’s cost for covered generic drugs until your costs total $6,350, unless you are already getting Medicare Extra Help.

Stage 3: Catastrophic Coverage Stage

Once you have paid enough for your drugs to move into this last payment stage, the plan will pay most of the cost of your drugs for the rest of the year.2

1 The Prominence Plus Plan provides Tier 1, 2 and 6 drugs during the Coverage Gap/Donut Hole. Contact the plan for more information.

2 You pay the greater of 5 percent or $3.60 for generic or preferred multi-source drugs and the greater of 5 percent or $8.95 for all other drugs.

NOTE: Eligible beneficiaries must use network pharmacies to access prescription drug benefits, except in nonroutine circumstances. Quantity limits and restrictions may apply.

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Last update 9/25/2019