CareAdvantage Dual Eligible Special Needs Plan (D-SNP) 2024

Medicine Costs

Premiums

CareAdvantage members do not pay monthly premiums because the Medicare Part B premium is covered by the Medi-Cal program.

Co-payments

Prescription medicine co-pays range from:

• $0, $1.55 or $4.50 for generic medicines
• $0, $4.60 or $11.20 for brand-name medicines

The amount of your co-pay will depend on:

• Whether you get a generic or brand-name medicine 
• Your income
• Whether you qualify for the Extra Help with Medicare Prescriptions Program
• How much you and HPSM have already paid in the current year for your prescriptions

There is no co-payment for:

• Over-the-counter medicines  covered by CareAdvantage
• Medi-Cal Rx covered medicines

Extra Help

If you have difficulty affording co-pays

You may qualify for the Extra Help with Medicare Prescriptions Program. Depending on your income and resources, you may be eligible for $0 medicine co-pays.

To apply for the Extra Help program:

• Call the Social Security Office 1-800-772-1213 TTY: 1-800-325-0778 Hours: Monday - Friday, 7:00 a.m. to 7:00 p.m.
• Call Medicare and ask for the Extra Help Program application: 1-800-MEDICARE (1-800-633-4227) TTY: 1-877-486-2048

Eligibility for the Extra Help Program

If Medicare does not have current or accurate information about your income and resources, you can present your claim to be eligible through the Best Available Evidence policy.

 By clicking on this link, you will be leaving the CareAdvantage website.

Prescription reimbursements

If you pay the full cost of a prescription, CareAdvantage will reimburse you under certain circumstances, such as when you:

• Fill a prescription in an emergency situation at a non-network pharmacy.
• Need a specialized medicine that is not available at a network pharmacy.
• Need a medicine that is only available, by law, at specific pharmacies.

Note that HPSM will not reimburse you for your Part D prescription co-pay.

To request reimbursement

Prescription reimbursement requests for CareAdvantage covered medicines and items should be submitted within one year (365 days). To request a prescription reimbursement, send us your bill and proof of any payment you have made. (Proof of payment can be a copy of the check you wrote or a receipt from the provider.) Mail these items to:

For information regarding prescription reimbursement requests for Medi-Cal Rx covered over-the-counter medicines and vitamins, please visit the Medi-Cal Rx website (www.medi-calrx.dhcs.ca.gov). You can also call the Medi-Cal Rx Customer Service Center at 1-800-977-2273.