Prescription drug coverage

Manage your medications with savings and convenience.

Part D prescription drug coverage

Our Medicare Advantage plans include Part D prescription drug coverage, making it easy to manage your prescription needs and expenses with one health plan.

Search for drugs in our online formulary.
View the 2023 Medicare Part D formulary (list of covered drugs) (PDF) (Updated 10/15/2022)
Formulario de la Parte D de Medicare Lista de medicamentos cubiertos (PDF)

Prior Authorization Medical Necessity Guidelines (PDF) (Updated 10/15/2022)
Step Therapy Medical Necessity Guidelines (PDF) (Updated 10/15/2022)

Looking for more pharmacy information? You can find drug coverage and pharmacy forms on our resources page.

 

$0 Preferred Generic Drugs

Tier 1 of the Formulary, Preferred Generic Drugs, covers commonly used generic medications at no additional cost. Talk to your doctor to see if these medications may be right for you.

 

Convenient pharmacy access

You have access to thousands of participating pharmacies, including all major pharmacy chains. Just show your Member ID card any time you fill a prescription. Prescriptions filled at non-contracted pharmacies are covered only in certain situations. 

Find a pharmacy near you.
View the 2023 Medicare Advantage Pharmacy Directory (PDF) (Updated 10/1/2022)
Directorio de farmacias (PDF)

 

Free home delivery (and extra savings)

Take advantage of savings on prescriptions you take regularly with the CVS Caremark Mail Service Pharmacy. Get a three-month supply of medication for only two co-pays. Shipping is free! 

 

Medicare Advantage 2022 Medicare Part D Coverage Details

Initial coverage period

Download details on costs for a 30-day supply from a retail pharmacy. Costs vary by plan.

 

Coverage in the Gap

Most Medicare drug plans have a coverage gap (also called the “donut hole”). This means that there’s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $4,660 After you enter the coverage gap, you pay 25% of the plan’s cost for covered brand-name drugs and 25% of the plan’s cost for covered generic drugs until your costs total $7,400, which is the end of the coverage gap. Not everyone will enter the coverage gap.

 

Reaching the $7,400 Catastrophic Coverage Limit in 2023

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,400, you pay the greater of: 5% of the cost, or $4.15 copay for generic (including brand drugs treated as generic) and a $10.35 copayment for all other drugs. You may get your drugs at network retail pharmacies and mail order pharmacies. 
 
Note: If you do not join a Medicare Part D plan when you first become eligible for Medicare, or do not have coverage as good as Medicare’s, you may have to pay a penalty if you join at a later date. This penalty will apply for as long as you are enrolled in Part D coverage.

 

Help with drug costs

You may be eligible for certain state and federal programs that reduce your monthly prescription drug premium or co-pays.

 

Low income subsidy

To see if you qualify, call 1-800-MEDICARE (1-800-633-4227) 24 hours a day, seven days a week. Or call the Social Security Office at 1-800-772-1213 Monday–Friday, 7 a.m.–7 p.m. (TTY 1-800-325-0778). You can also call your state Medicaid office.

 

Pharmaceutical assistance programs

To ask if you qualify, call: 

Prescription Advantage 
P.O. Box 15153 
Worcester, MA 01615-0153 
1-800-243-4636, Monday – Friday , 9:00 AM – 5:00 PM 

 

Medication Therapy Management Program

The Medication Therapy Management Program (MTMP) is your chance to review your medications and over-the-counter products with a pharmacist. Learn more about this program that is free to all Medicare members. 

Medicare Advantage Part D Transition Fill Policy

Mass General Brigham Health Plans Part D Transition Policy exists to provide new (and some current) enrollees immediate access to prescription drugs within 90 days of enrollment for non-formulary drugs and drugs with utilization management requirements, such as the need for a prior authorization from us.

  • Who is eligible for a transitional supply?

    A transitional supply, or transition fill, is available to members within 90 days of your enrollment effective date in the following circumstances:

    • Join or switch drug plans during the annual Open Enrollment Period between Oct 15-Dec 7,
    • Join or switch drug plans during the year using another type of enrollment period (e.g., Initial Enrollment Period, Special Enrollment Period, or Medicare Advantage Open Enrollment Period),
    • New and current plan members who live in long-term care (LTC) facilities, and
    • May be available to some current plan members who are negatively affected by formulary changes from one plan year to the next.
  • Does the transition policy apply to all drugs?

    The transition policy does not apply to Part D excluded drugs, new prescriptions, or to drugs that have been removed from a plan’s formulary because of FDA safety recalls. The transition policy does apply to both non-formulary drugs and drugs with utilization management requirements.

  • What is utilization management?

    Utilization management (UM) is a restriction or action required by your plan before we will pay for medication. Quantity limits, step therapy, or prior authorization are common utilization management restrictions. These restrictions often require a doctor or prescriber to submit information about your medical condition or treatment before we can pay for the medication, even though the drug is on the formulary.

  • What do I do next?

    You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take.

We’re Here for You.
Call 855-486-3097 (TTY 711)

Seven days a week, 8 AM-8 PM Eastern Time 

April 1-September 30, Monday-Friday 8 AM-8 PM