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Prescription Drug Coverage

All SummaCare Medicare Advantage plans (except the Amber (HMO) plan) include Medicare (Part D) prescription drug coverage for no additional monthly plan premium. You can see the complete plan formulary (list of covered drugs) or use our Find Your Drug tool to search for a specific drug.

The SummaCare Medicare Formulary (Drug List)

The SummaCare Medicare Formulary is a list of covered drugs under SummaCare Medicare Advantage plans. SummaCare will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a network pharmacy (except in non-routine circumstances) and other plan rules are followed.

SummaCare covers both brand name drugs and generic drugs. Generic drugs have the same active-ingredient formula as brand name drugs.

Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs.

The formulary and pharmacy network may change at any time. You will receive notice when necessary.

Check to see if your drug is covered.  

If you enroll in SummaCare and notice your drug is not included in the SummaCare Medicare Formulary, contact us to confirm your drug is not covered.

Pharmacy Benefits and Travel

SummaCare will cover your prescriptions at in-network pharmacies under the applicable co-payment amount while you travel throughout the United States. Our pharmacy network includes most national chains, plus many local, independent pharmacies. If traveling, your out-of-pocket costs may be higher if you fill a prescription at an out-of-network pharmacy.

In general, you must use in-network pharmacies to access your prescription drug benefit, except in non-routine circumstances. Quantity limitations and restrictions may apply.

Search for a network pharmacy.

Tiers & Drug Costs

Our plan groups each medication into one of six “tiers.” You will need to use SummaCare’s Medicare Formulary (list of covered drugs) to locate what tier your drug is in to determine how much it will cost you. The amount you pay depends on the drug’s tier and what stage of the benefit you have reached. Tier 1 preferred generic drugs and Tier 6 Select Care Drugs (includes Vaccines) are covered at a $0 copay and are covered through the coverage gap.

  • Tier 1: Preferred Generic ($0 copay for all plans)
  • Tier 2: Generic
  • Tier 3: Preferred Brand Name
  • Tier 4: Non-Preferred
  • Tier 5: Specialty
  • Tier 6: Select Care Drugs Including Vaccines ($0 copay for all plans)

Some common generic over-the-counter (OTC) drugs are covered at a $0 copay if prescribed by a doctor. 

Coverage Stages

When shopping for Medicare coverage, you’ve probably heard the term “donut hole.” This happens when you experience a gap in Medicare prescription drug coverage and pay more out-of-pocket costs on medications – otherwise known as the “coverage gap.” Not everyone will reach this coverage gap. It occurs when your total prescription drug costs reach $5,030 for the 2024 calendar year – this is the amount of drug costs paid by SummaCare and you.

Stage 1: Your Annual Deductible

All of our plans feature a $0 deductible for pharmacy coverage.

Stage 2: Your Initial Coverage Period $0-$5,030

During the calendar year, you pay predictable copays or coinsurance on your prescriptions based on the tier the drug is assigned within our formulary. When your year-to-date total drug costs reach $5,030 (the amount you’ve paid in copays and coinsurance plus the amount SummaCare has paid), you will enter the coverage gap.

Stage 3: The Coverage Gap

While in the coverage gap, SummaCare Medicare Advantage plans cover Tier 1 preferred generics and Tier 6 Select Care Drugs (includes Vaccines) at a $0 copay. For drugs in other Tiers, your out-of-pocket costs on prescriptions may increase. For all generic and brand name drugs, you’ll pay 25% of the cost. To help reduce your costs, discounts and plan payments will apply to all of your prescriptions. If you receive extra help for prescriptions, your costs may be even lower.

Stage 4: Catastrophic Coverage $8,000

This stage is designed to help individuals with extremely high drug costs. You reach this stage when your total year-to-date, out-of-pocket drug costs reach $8,000. If you reach this stage, the plan pays the full cost for your covered Part D drugs. You pay nothing.

Find Your Drug

Use our online search to find out what drugs are covered and/or locate what tier your drug is in to determine how much it will cost you. 

Learn More About Our Prescription Drug Coverage

View the SummaCare Medicare drug list, learn how our mail-order pharmacy can save you money and find out what drugs have quantity limits, step therapy or prior authorization requirements.