PSHP Prescription Coverage

Prescription drugs are an important consideration when making decisions about your medical coverage. Part D is the Medicare prescription drug program. The program is managed by private companies approved by CMS and is a voluntary benefit. However, penalties may apply if you don't sign up for Medicare Part D at the time you are initially eligible. Monthly premiums vary by plan and product selected.

PSHP has four benefit plans that provide coverage for Part D. We have two formularies (list of covered drugs) that describe the coverage for each plan. Below is a chart that outlines the coverage for each benefit plan. You may click on the Formulary buttons to see the drug tier, copayment and any limitations for each of the covered drugs listed in the Formulary.

	Partners Sound+Rx	Partners Charter+Rx	Partners Apex +Rx*	Partners Summit+Rx
Deductible	$310 Preferred Generics $5 copayment	$0	$0	$0
Tier I - Preferred Generics copayment	$5	$5	$5	$5
Tier II - Preferred Brand copayment	$29	$29	$29	$29
Tier III - Specialty Drugs coinsurance	20%	20%	20%	20%
Tier IV - Non-Preferred Brand copayment	$59	$59	$59	$59
Coverage Gap	$4,550	$4,550	$4,550 Preferred Generics $5 copayment	$4,550 Preferred Generics $5 copayment

*same for Partners Apex +Rx King County

For additional information regarding Part D coverage, please refer to the Evidence of Coverage.

Extra Help Paying for Prescription Medications

For beneficiaries who qualify, Medicare provides Part D premium and cost-sharing assistance through the program's low income subsidy, also called the LIS. Individuals who qualify for extra help pay $0 or a reduced monthly premium. For additional information click here.

Important Links and Information:

If a beneficiary would like to appoint a person to file a grievance, request a coverage determination or exception, or request an appeal on his or her behalf, the beneficiary and the person accepting the appointment must fill out this form (or a written equivalent) and submit it with the request. Click here for more information.
To request for Medicare Prescription Drug Determination Request Form (for use by enrollees) located on CMS’s Part D appeals webpage. Click Here
Medicare Part D Coverage Determination Request Form (for use by provider) located on CMS’s Part D appeals webpage. Click Here
To review information about prior authorizations that are needed for certain prescriptions click here for the PSHP Formulary or click here for the Star Formulary. Or, for information about step therapy requirements on the Star Formulary click here.
Negative changes for Star click here.
Negative changes for PSHP click here.