Prescription Drug Coverage with the TRAIL MAPD Program

Prescription drug coverage provided under a TRAIL MAPD plan includes Medicare Part D prescription drug coverage. Prescription drug formularies (i.e., list of drugs covered) vary by health plan. The TRAIL MAPD prescription drug coverage must follow Medicare rules for which types of drugs can be covered. Drugs covered under a non-Medicare Part D plan may not be covered under a Medicare Part D plan. If you are uncertain whether a drug will be covered, you should call the health plan in which you are interested in enrolling to inquire.

Since the TRAIL MAPD prescription drug coverage is a Medicare Part D plan, the member’s cost for prescription drugs under the TRAIL MAPD Program must follow the Medicare Part D drug coverage stages. There are four drug payment stages: Annual Deductible, Initial Coverage, Coverage Gap, and Catastrophic Coverage. At the beginning of the year, you start out in the Annual Deductible stage. If the plan has no prescription drug deductible, then you begin in the second stage, the Initial Coverage stage. You progress to the next stage once you have met the cost requirements for the current stage.

Unlike a standard Part D plan in which the enrollee is required to pay a percentage of the full retail cost of the drug, State members enrolled in the TRAIL MAPD Program pay only the plan’s standard copayment through the Initial Coverage and Coverage Gap stages. Paying only the standard copayment through the Coverage Gap is a valuable benefit for TRAIL MAPD members. Once a member reaches the Catastrophic Coverage stage (when the true out-of-pocket costs reach $7,050 for prescription drugs in 2022), the member will pay either a small copayment or 5% coinsurance that is capped to limit a member’s out-of-pocket costs.

Medicare requires those enrolled in a Medicare Part D plan whose annual income is above a certain limit to pay an additional premium called IRMAA (Income-Related Monthly Adjustment Amount). Medicare will look back at your tax return from two years ago to determine your income. For those members whose income is verified by the IRS to exceed the established limits, the Social Security Administration will send a predetermination letter. If applicable, IRMAA applies to both Medicare Parts B and D; therefore, members who pay an additional premium for their Medicare Part B coverage are the same members who will be charged the Medicare Part D IRMAA amount. Members will receive a quarterly bill in the mail from Social Security for these additional premiums. To remain in the Medicare Advantage plan, affected members must pay these additional premiums. Go to medicare.gov for IRMAA premium amounts.