2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 6: What you pay for your Part D prescription drugs 162 Medicare has rules about what counts and what does not count toward your out-of-pocket costs. Here are the rules we must follow to keep track of your out-of-pocket costs. These payments are included in your out-of-pocket costs Your out-of-pocket costs include the payments listed below (as long as they are for Part D covered drugs and you followed the rules for drug coverage that are explained in Chapter 5): · The amount you pay for drugs when you are in any of the following drug payment stages: - The Deductible Stage - The Initial Coverage Stage - The Coverage Gap Stage · Any payments you made during this calendar year as a member of a different Medicare prescription drug plan before you joined our plan. It matters who pays: · If you make these payments yourself, they are included in your out-of-pocket costs. · These payments are also included in your out-of-pocket costs if they are made on your behalf by certain other individuals or organizations. This includes payments for your drugs made by a friend or relative, by most charities, by AIDS drug assistance programs, by a State Pharmaceutical Assistance Program that is qualified by Medicare, or by the Indian Health Service. Payments made by Medicare’s “Extra Help” Program are also included. · Some payments made by the Medicare Coverage Gap Discount Program are included in your out-of-pocket costs. The amount the manufacturer pays for your brand name drugs is included. But the amount the plan pays for your generic drugs is not included. Moving on to the Catastrophic Coverage Stage: When you (or those paying on your behalf) have spent a total of $8,000 in out-of-pocket costs within the plan year, you will move from the Coverage Gap Stage to the Catastrophic Coverage Stage. These payments are not included in your out-of-pocket costs Your out-of-pocket costs do not include any of these types of payments: · Drugs you buy outside the United States and its territories. · Drugs that are not covered by our plan. · Drugs you get at an out-of-network pharmacy that do not meet the plan’s requirements for out- of-network coverage. · Prescription drugs covered by Part A or Part B. · Payments you make toward drugs covered under our additional coverage but not normally covered in a Medicare Prescription Drug Plan. · Payments you make toward prescription drugs not normally covered in a Medicare Prescription Drug Plan.