Soundpath Health Prescription Drug Information

About Medicare Part D and Prescription Drug Coverage: Soundpath Health

Medicare Part D plans provide prescription drug coverage to beneficiaries who elect to enroll in a prescription drug plan (as long as they do not already have prescription drug coverage through an employer or union, TRICARE for Life, Cobra or other means). Anyone who has Part A and Part B and lives in a plan's service area is eligible to enroll. People with Medicare can obtain prescription drug coverage by either joining a standalone Part D Prescription Drug Plan or Joining a Medicare Advantage plan. A Medicare Advantage plan includes Part D prescription drug coverage. The Part D program is managed by private companies approved by CMS and is a voluntary benefit. Monthly premiums vary by plan and product selected.


Network Pharmacies

When your plan includes Part D prescription coverage, you can use any of the pharmacies in our extensive pharmacy network to have your covered prescriptions filled.

Plus, we offer a prescription drug home delivery service that can provide a convenient way to receive your long-term prescription drugs. To set up an account, track prescription history and order prescriptions visit optumrx.com (this link will direct you to a new website.) The home delivery phone number is also on the back of your ID card for easy reference.

To locate a pharmacy, call Customer Service, or click here to review the 2018 Provider/Pharmacy Directory. You may also call Customer Service and ask us to mail you a printed copy of our Provider/Pharmacy Directory.

 

Formularies

Each Medicare Prescription Drug Plan has a formulary (list of covered drugs). Even if a drug is on the plan's formulary, there may be special rules for filling the prescription. Some of these rules may include:

  • Limiting the quantity of a drug that we cover over a certain period of time for safety and cost reasons.
  • Prior authorization from the plan may be required before a prescription will be covered to ensure drugs are used correctly and only when medically necessary.
  • There may be a Step Therapy requirement to try certain drugs before a formulary drug is covered.
Drugs may also have different cost-sharing levels, called tiers. You may view the 2018 Comprehensive Formulary to see the drug tier, copayment and any limitations for each of the covered drugs listed in the Formulary. Soundpath Health members receive an Abridged Formulary, which is a partial list of covered drugs.

Quality Assurance Policies and Procedures

A Medicare Prescription Drug Plan must have established quality assurance measures and systems to reduce medication errors and adverse drug interactions and improve medication use. Soundpath Health has options to help our members including our Medication Therapy Management (MTM) program (Click here to view page)please also view our Patient Safety and Quality Improvement Program Document and Transition Policy for more information, see link below. 


Late Enrollment Penalty

Beneficiaries who don't enroll in a Medicare Prescription Drug Plan when they are first eligible may have to pay a late enrollment penalty to enroll in a plan later if they don't maintain creditable coverage. Most people who wait until after the end of their Initial Enrollment Period (IEP) to join a plan will have their premiums go up 1% for every month they waited to enroll. These individuals usually have to pay this penalty as long as they have Medicare prescription drug coverage.

What Part D covers

  • Part D is voluntary and is designed to supplement Part A and Part B coverage

  • All drugs mandated by Medicare

What Part D 
Doesn't Cover

  • Drugs not on the Medicare formulary

  • Certain drugs that are covered under Part B

 

Limitations: Coverage may vary by plan and plan type. It's important to review options carefully.


2018 PART D BENEFIT*

CHARTER+RX

PEAK+RX

SOUND+RX

Monthly Premium

$146 per month

$0 per month

$40 per month

Part D Deductible

$0 per year Tier 1 and tier 2. 
$160.00 per year for drugs on Tier 3, Tier 4 and Tier 5.

$0 per year Tier 1 and tier 2. 
$160.00 per year for drugs on Tier 3, Tier 4 and Tier 5.

$0 per year Tier 1 and tier 2. 
$160.00 per year for drugs on Tier 3, Tier 4 and Tier 5.

Prescription Drug 31-day Supply Retail, Long Term Pharmacy Care, or Mail Order

Tier 1: $2 copay
Tier 2: $12 copay
Tier 3: $47 copay
Tier 4: 50% coinsurance 
Tier 5: 30% coinsurance

Tier 1: $3 copay
Tier 2: $14 copay
Tier 3: $47 copay
Tier 4: 50% coinsurance 
Tier 5: 30% coinsurance

Tier 1: $2 copay
Tier 2: $12 copay
Tier 3: $47 copay
Tier 4: 50% coinsurance 
Tier 5: 30% coinsurance

Prescription Drug 62-day supply Retail, Mail Order

Tier 1: $4 copay
Tier 2: $24 copay
Tier 3: $94 copay
Tier 4: 50% coinsurance 
Tier 5: Not Covered

Tier 1: $6 copay
Tier 2: $28 copay
Tier 3: $94 copay
Tier 4: 50% coinsurance 
Tier 5: Not Covered

Tier 1: $4 copay
Tier 2: $24 copay
Tier 3: $94 copay
Tier 4: 50% coinsurance 
Tier 5: Not Covered

Prescription Drug 93-day Supply Retail

Tier 1: $5 copay
Tier 2: $30 copay
Tier 3: $117.50 copay
Tier 4: 50% coinsurance 
Tier 5: Not Covered

Tier 1: $7.50 copay
Tier 2: $35 copay
Tier 3: $117.50 copay
Tier 4: 50% coinsurance 
Tier 5: Not Covered

Tier 1: $5 copay
Tier 2: $30 copay
Tier 3: $117.50 copay
Tier 4: 50% coinsurance 
Tier 5: Not Covered

Prescription Drug 93-day Supply Mail Order

Tier 1: $5 copay
Tier 2: $30 copay
Tier 3: $117.50
copay
Tier 4: 50% coinsurance 
Tier 5: Not Covered

Tier 1: $7.50 copay
Tier 2: $35 copay
Tier 3: $117.50
copay
Tier 4: 50% coinsurance 
Tier 5: Not Covered

Tier 1: $5 copay
Tier 2: $30 copay
Tier 3: $117.50
copay
Tier 4: 50% coinsurance 
Tier 5: Not Covered


Note: Members of our plan generally must use network pharmacies to receive plan coverage. You may choose to have your prescription drugs shipped to your home through the network mail order delivery program. For refills, please contact your pharmacy before you run out of the prescription drugs you have on hand. Usually, a mail-order pharmacy order will get to you within 14 days. If your mail order prescription drug is delayed, we recommend you contact the mail-order pharmacy directly. If you have questions or concerns, the Customer Service phone number is listed on your ID card. Quantity limitations and restrictions may apply.

* For complete information about your benefits, and about limitations or restrictions to your medical or drug benefits, please see Chapters 4, 5, and 6 in your Evidence of Coverage (EOC) document.

 Pharmacy Service Area: Washington State


IMPORTANT INFORMATION
REGARDING PART D COVERAGE

Access Important Information For Part D Coverage
2018 Soundpath Health Transition Policy Download
2018 Comprehensive Formulary Download
2018 Prior Authorization Requirements Download
2018 Step Therapy Requirements Download
2018 Summary of Benefits for Charter +Rx, 
Peak +Rx and Sound Rx
Download
Part D Coverage Determination Request Form Download
Soundpath Health ONLINE Part D Coverage Determination Requests through Optum Rx 
(Note: This link takes you to a non-Medicare site)
View Page
Appeals and Grievances Information: 
View Page
CMS Best Available Evidence Policy (Note: This link will direct you to a different website.) View Page
CMS Coverage Redetermination Requests Forms and Tools (Note: This link will direct you to a different website.) View Page
 CMS Coverage Determination Requests Forms and Tools (Note: This link will direct you to a different website.)
  View Page



Page Last Updated: November 01, 2018