Filling Your Prescriptions

What is Medicare Part D?

Medicare Part D is the prescription drug coverage of Medicare. The benefit is administered by commercial insurance plans, either as a stand alone prescription drug plan or as a part of a Medicare Advantage plan that includes Part D, like Cover. Most of your prescriptions will be covered by your Part D benefit, but some are covered as a part of your medical benefits. To learn more about how a drug you take is covered, contact Member Services.

What is a prescription drug formulary?

A formulary is a list of drugs covered by your plan. Clover's formulary is maintained by Clover's Pharmacy department and Medicare. Clover updates the plan formularies as necessary to include new medications, or to adjust how some medications are covered. If something changes that affects your costs, we'll notify you in advance. Go here to see Clover's complete formulary for each of our plans

If you're currently taking a drug that isn't in our formulary, you can request an exception. See our Drug Transition Policy here.

What is the Gap Phase of my coverage, or Coverage Gap?

The Coverage Gap is a period of reduced coverage common across most Medicare Advantage Part D drug plans. There are four phases of Part D coverage, including the Gap Phase. After you pay your plan's deductible, you pay the copays or co-insurance described in your plan benefits till the total cost of your prescriptions reaches a certain amount.

The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3,750. Not everyone will enter the coverage gap. If you do reach the Gap Phase of your coverage, you'll pay more for your prescriptions until you reach the end of that phase. At the end of the Gap Phase, you'll pay a low, fixed amount till the end of the plan year for all your Part D prescriptions. If you have questions about your own Part D costs, or extra help you might be eligible for in paying those costs, please contact Member Services.

How will my prescription drug costs change throughout the year?

See the example below for an idea of how a fictional example member's drug costs change through the year.

Member Joe takes four medications:

Drug A, which is generic, tier 2, and costs $50/month without insurance
Drug B, which is generic, tier 2, and costs $100/month without insurance
Drug C, which is brand name, tier 1, and costs $200/month without insurance
Drug D, which is brand name, tier 4, and costs $380/month without insurance

Without insurance, Joe would pay $730/month