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AlohaCare Advantage Drug Benefits (HMO D-SNP)

You Pay

Annual drug deductible

$0
Because you receive Extra Help you do not have an annual drug deductible

Initial coverage stage
Until you’ve paid $2,100 out of pocket for Part D drugs.

30-day, 60-day, 90-day and 100-day supply from retail pharmacies 

Tier 1 - Preferred Generic

Tier 2 – Generic

Tier 3 - Preferred Brand
Tier 4 - Non-preferred Drug
Tier 5 - Specialty 

For generic drugs: $0, $1.60, or $5.10.
For brand drugs: $0, $4.90, or $12.65.
Copayments for drugs may vary based on the level of Extra Help you get. Refer to your “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” letter (also known as the Low-Income Subsidy Rider), which tells you about your level of Extra Help you receive for your drug coverage.

Tier 6 – Select Care Drugs (generic hypertension, generic cholesterol and generic diabetes drugs)

$0

Up to 100-day supply from mail-order pharmacy 

Tier 1 - Preferred Generic

Tier 2 - Generic

Tier 3 - Preferred Brand
Tier 4 - Non-preferred Drug
Tier 5 - Specialty 

For generic drugs: $0, $1.60, or $5.10.
For all other drugs: $0, $4.90, or $12.65.
Copayments for drugs may vary based on the level of Extra Help you get. Refer to your “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” letter (also known as the Low-Income Subsidy Rider), which tells you about your level of Extra Help you receive for your drug coverage.

Tier 6 – Select Care Drugs (generic hypertension, generic cholesterol and generic diabetes drugs)

$0

Catastrophic coverage stage
After you’ve paid $2,100 out-of-pocket for Part D drugs. 

Part D drug copays $0 

Part D vaccines

$0

AlohaCare Advantage Plus Drug Benefits (HMO D-SNP)

You Pay

Annual drug deductible

$0
Because you receive Extra Help you do not have an annual drug deductible

Initial coverage stage
Until you’ve paid $2,100 out of pocket for Part D drugs.

30-day, 60-day, 90-day and 100-day supply from retail pharmacies 

Tier 1 - Preferred Generic

Tier 2 - Generic

Tier 3 - Preferred Brand
Tier 4 - Non-preferred Drug (Generic or Brand Drug)
Tier 5 - Specialty 

For generic drugs: $0, $1.60, or $5.10.
For brand drugs: $0, $4.90, or $12.65.
Copayments for drugs may vary based on the level of Extra Help you get. Refer to your “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” letter (also known as the Low-Income Subsidy Rider), which tells you about your level of Extra Help you receive for your drug coverage.

Tier 6 – Select Care Drugs (generic hypertension, generic cholesterol and generic diabetes drugs)

$0

Formulary OTC

$0

Up to 100-day supply from mail-order pharmacy 

Tier 1 - Preferred Generic

Tier 2 - Generic

Tier 3 - Preferred Brand
Tier 4 - Non-preferred Drug (Generic or Brand Drug)
Tier 5 - Specialty 

For generic drugs: $0, $1.60, or $5.10.
For all other drugs: $0, $4.90, or $12.65.
Copayments for drugs may vary based on the level of Extra Help you get. Refer to your “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” letter (also known as the Low-Income Subsidy Rider), which tells you about your level of Extra Help you receive for your drug coverage.

Tier 6 - Select Care Drugs (generic hypertension, generic cholesterol and generic diabetes drugs)

$0

Formulary OTC

$0

Catastrophic coverage stage

After you’ve paid $2,100 out-of-pocket for Part D drugs.

Part D drug copays $0 

Part D vaccines

$0