Medicare Part D

To learn more about our Part D prescription drug benefits, please review the plan’s Summary of Benefits. The document highlights applicable premiums, copayments, coinsurance and deductibles. Please refer to the Evidence of Coverage for a complete explanation of benefits.

Find Evidence of Coverage

Important Message About What You Pay for Vaccines: Our plan covers most Part D vaccines at no cost to you even if you haven't paid your deductible.* Call Member Services for more information.

Important Message About What You Pay for Insulin: You won't pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it's on, even if you haven't paid your deductible.*

Getting Help from Medicare: If you chose this plan because you were looking for insulin coverage at $35 a month or less, it is important to know that you may have other options available to you for 2026 at even lower costs because of changes to the Medicare Part D program. Contact Medicare, at 1-800- MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week for help comparing your options. TTY users should call 1-877-486-2048.

Additional Resources to Help: Please contact our Member Services number at 1-866-634-2247, TTY: 711, for additional information. Hours are 8:00 a.m. to 8:00 p.m., 7 days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30.

*Deductible plans: AZ H3443 005 Alignment Health smartHMO (HMO), AZ H3443 006 Alignment Health Heart & Diabetes Plus (HMO C-SNP), AZ H4334 007 Alignment Health Heart & Diabetes AZPlus (HMO C-SNP), CA H3815 030 Alignment Health CalPlusDuals (HMO D-SNP), CA H3815 038 Alignment Health smartHMO (HMO), CA H3815 039 Alignment Health Heart & Diabetes CalPlus (HMO C-SNP), CA H3815 040 Alignment Health smartHMO (HMO), CA H3815 041 Alignment Health BreathEasy (HMO C-SNP), CA H3815 042 Alignment Health Clarity (HMO C-SNP), CA H3815 044 Alignment Health Heart & Diabetes Access (HMO C-SNP), CA H3815 045 Alignment Health Silicon (HMO C-SNP), CA H3815 051 Alignment Health Heart & Diabetes Choice (HMO C-SNP), CA H3815 052 Alignment Health Honor+ Plan (HMO), CA H3815 056 Alignment Health S.D. Premium Giveback (HMO), CA H8832 003 Alignment Health Freedom (PPO), NC H5296 004 Alignment Health NC Duals (HMO-POS D-SNP), NC H5296 006 Alignment Health smartHMO (HMO), NC H5296 009 Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP), NC H5296 0010 Alignment Health Platinum Select (HMO), NC H5296 011Alignment Health Heart & Diabetes Care (HMO C-SNP), NV H5296 008 Alignment Health smartHMO (HMO), NV H9686 005 Alignment Health the ONE (HMO D-SNP)/ Alignment Health el ÚNICO (HMO D-SNP), NV H9686 006 Alignment Health Heart & Diabetes NVPlus (HMO C-SNP), NV H9686 008 Alignment Health smartHMO (HMO), TX H5472 003 Alignment Health smartHMO (HMO-POS), TX H5472 004 Alignment Health Heart & Diabetes Plus (HMO-POS C-SNP), TX H5472 007 Alignment Health Dual Select+ (HMO-POS D-SNP), TX H5472 009 Alignment Health Total Dual+ (HMO-POS D-SNP), TX H5472 010 Alignment Health smartSavings (HMO-POS).

We cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. To help you, we have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan. If you cannot use a network pharmacy, here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:

• If you are unable to get a covered drug in a timely manner within our service area, because there are no network pharmacies within a reasonable driving distance that provide 24-hour service
• If you are trying to fill a covered prescription drug that is not regularly stocked at a network retail or mail order pharmacy (these drugs include orphan drugs or other specialty pharmaceuticals)
• If you are traveling outside of our service area and run out of, lose, or become ill and need a covered drug
• If you are provided a covered drug while in an emergency department, provider-based clinic, outpatient surgery or other outpatient setting and unable to get the drug filled at a network pharmacy
• If you are evacuated or displaced from your residence, due to a federally- declared disaster or other public health emergency declaration, and unable to get the covered drug at a network pharmacy

In these situations, please check first with Member Services to see if there is a network pharmacy nearby. You may be required to pay the difference between what you pay for the drug at the out-of-network pharmacy and the cost that we would cover at an in-network pharmacy.

How do you ask for reimbursement from the plan?
If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than your normal share of the cost) at the time you fill your prescription. You can ask us to reimburse you for our share of the cost. Please refer to your plan’s Evidence of Coverage for a complete explanation of how to ask the plan to pay you back.

We conduct drug use reviews for our members to help make sure that they are getting safe and appropriate care. These reviews are especially important for members who have more than one provider who prescribes their drugs.

We do a review each time you fill a prescription. We also review our records on a regular basis. During these reviews, we look for potential problems such as:

• Possible medication errors
• Drugs that may not be necessary because you are taking another drug to treat the same medical condition
• Drugs that may not be safe or appropriate because of your age or gender
• Certain combinations of drugs that could harm you if taken at the same time
• Prescriptions written for drugs that have ingredients you are allergic to
• Possible errors in the amount (dosage) of a drug you are taking
• Unsafe amounts of opioid pain medications

If we see a possible problem in your use of medications, we will work with your provider to correct the problem.

Prior authorization is required on some drugs before they are covered. If your health plan's drug list requires prior authorization for a specific drug, your doctor must submit a prior authorization request form for approval.

View Criteria and Request Form

In some cases, Alignment Health Plan may require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. This is called step therapy, which is a managed care approach to taking prescription drugs.

View Criteria

The process for coverage decisions and appeals can be found in Chapter 9 of your evidence of coverage (EOC). This is the process you use for issues such as whether something is covered or not and the way in which something is covered. Please refer to Chapter 9 of your EOC for a full description of the process.

Find Evidence of Coverage

When you are asking for a coverage decision or making an appeal, you can ask someone to act on your behalf. If you want to, you can name another person to act for you as your “representative” to ask for a coverage decision or make an appeal. The Appointment of Representative form gives that person permission to act on your behalf. It must be signed by you and by the person who you would like to act on your behalf. Contact Member Services to send us the signed form.

View Form

A coverage decision is a decision that Alignment Health Plan makes about benefits and coverage or about the amount the plan will pay for medical services or drugs. An initial coverage decision about Part D drugs is called a “coverage determination.” Learn more

To request an initial coverage decision about Part D drugs over the web, please complete our Coverage Determination Form.

Coverage Determination Form

If Alignment Health Plan denies your request for coverage of (or payment for) a prescription drug, you have the right to ask us for a redetermination (appeal) of our decision. Learn more

Coverage Redetermination Form

If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our Plan.

View LIS Levels

Alignment Health Plan has a free voluntary program for members who have multiple medical conditions, take many prescription drugs, and have high drug costs. It is available to you at no cost if you qualify.

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Alignment Health Plan 為患有多種疾病、服用多種處方藥且藥費高昂的會員提供一項免費的自願參與計劃。如果您符合資格，則可以免費使用此計劃。

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Alignment Health Plan tiene un programa voluntario gratuito para miembros que tienen múltiples afecciones médicas, toman muchos medicamentos con receta y tienen altos costos de medicamentos. Está disponible para usted sin costo alguno si reúne los requisitos.

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Alignment Health Plan có chương trình tình nguyện miễn phí cho thành viên mắc nhiều bệnh trạng y tế, dùng nhiều loại thuốc kê toa và có chi phí thuốc cao. Chương trình này được cung cấp miễn phí cho quý vị nếu quý vị hội đủ điều kiện.

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This procedure describes the standard process that Alignment Health Plan, its divisions and subsidiaries, and its pharmacy benefit manager (PBM), use to develop and maintain the Medicare Transition Program.

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The Medicare Prescription Payment Plan is a new payment option that works with your current drug coverage, and it can help you manage your drug costs by spreading them across monthly payments that vary throughout the year (January – December). This payment option might help you manage your expenses but doesn’t save you money or lower your drug costs. “Extra Help” from Medicare and help from programs like your State Pharmaceutical Assistance Program (SPAP) and Manufacturer Pharmaceutical Assistance Program (MPAP), for those who qualify, is more advantageous than participation in the Medicare Prescription Payment Plan. All members are eligible to participate in this payment option, regardless of income level, and all Medicare drug plans and Medicare health plans with drug coverage must offer this payment option. See if this payment option will help you at: medicare.gov/prescription-payment-plan/will-this-help-me

Medicare Prescription Payment Plan Fact Sheet

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Medicare 处方付款计划是一种新的付款选项，可与您现有的药物保险配合使用。它通过将药费分摊到全年（1 月至 12 月）不同的每月付款中来帮助您管理药费。这种付款选项可能有助于您管理开支，但不能为您省钱或降低药费。对于符合条件的人来说，参加 Medicare 的“额外补助”以及诸如州政府医药补助计划 (SPAP) 和制造商药物援助计划 (MPAP) 等计划比参加 Medicare 处方付款计划更有利。所有会员均有资格参加此付款选项，无论收入水平如何，并且所有 Medicare 药物计划和包含药物承保的 Medicare 健康计划都必须提供此付款选项。看看这个付款选项是否对您有帮助：medicare.gov/prescription-payment-plan/will-this-help-me

Medicare Prescription Payment Plan Fact Sheet

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