2018 Plans

Elite D Plan

Jun 15, 2017, 17:53 PM
Copayment Plan Name : Elite D - 2017 Copayment Amounts
Exam : No
This plan includes prescription drug coverage.
$20 copay/visit
$20 copay/visit
$75 copay/visit
Covered at 100%
$500 copay/stay

Days 1 - 20: $0

Days 21 - 100: $125 copay/day

Initial eye exam: $0

Eyewear: $300 for frames and lenses

(available through Gundersen Health System Audiology)

Hearing exam: $0

Hearing Aids: $675-$2,075 copay/aid

Limit: 1 per ear/year

Covered in full
Covered in full
This plan includes Part D coverage.
Learn more here.
  • There is no Part D prescription deductible.

Before the total yearly drug costs (paid by both you and Senior Preferred Elite D) reach $3,700, you pay the following amounts for prescription drugs when they are filled at a retail pharmacy.

Mail Order Pharmacy copayment amounts are also noted below.

  • Tier 1 - (Preferred Generic) Copayment Amounts   
    • Retail Pharmacy
      • One-month (30 day) supply - $3
      • Three-month (90 day) supply - $9
    • Mail Order Pharmacy
      • Three-month (90 day) supply - $7


  • Tier 2 - (Generic) Copayment Amounts   
    • Retail Pharmacy
      • One-month (30 day) supply - $15
      • Three-month (90 day) supply - $45
    • Mail Order Pharmacy
      • Three month (90 day) supply - $38


  • Tier 3 - (Preferred Brand) Copayment Amounts   
    • Retail Pharmacy
      • One-month (30 day) supply - $45
      • Three-month (90 day) supply - $135
    • Mail Order Pharmacy
      • Three month (90 day) supply - $113


  • Tier 4 - (Non-Preferred Drug) Coinsurance Amounts
    • Retail Pharmacy
      • One-month (30 day) supply - You pay 40% of the cost.
      • Three-month (90 day) supply - You pay 40% of the cost.
    • Mail Order Pharmacy
      • Three month (90 day) supply - You pay 40% of the cost.


  • Tier 5 - (Specialty Medications) Coinsurance Amounts
    • Retail Pharmacies
      • One-month (30 day) supply - You pay 33% of the cost.
      • We do not cover three-month (90 day) supplies of Tier 5 medications at retail pharmacies.
    • Mail Order Pharmacy
      • One-month (30 day) supply - You pay 33% of the cost. 
      • We do not cover three-month (90 day) supplies of Tier 5 medications through mail order pharmacy.


If you reside in a long-term care facility, you pay the same as at a retail pharmacy.

You may get drugs from at out-of-network pharmacy, but you may pay more than you pay at an in-network pharmacy.

After your total yearly drug costs (paid by both you and Senior Preferred EliteD) reach $3,700, you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 40% for the plan's costs for brand name drugs and 51% of the plan's costs for generic drugs until your yearly out-of-pocket drug costs reach $4,950.
After your yearly out-of-pocket drug costs reach $4,950 you pay the greater of 5% of the cost or $3.30 copay for generic (including brand drugs treated as generic) and $8.25 for all other drugs.


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Out-of-network providers

In most cases, care you receive from an out-of-network provider (a provider who is not part of our plan’s network) will not be covered. These are three exceptions:

1. The plan covers emergency care or urgently needed care that you get from an out-of-network provider. For more information about this, and to see what emergency or urgently needed care means, see Section 3 in the Evidence of Coverage (links to the Evidence of Coverage documents can be found above).

2. If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. If your network provider suggests or recommends care out-of-network, a referral must be obtained in writing, and signed by the plan’s medical director prior to seeking care. In this situation, you will pay the same as you would pay if you got the care from a network provider.

3. Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area.

Using a pharmacy that is out of the network

There are special circumstances when our plan will cover prescriptions from out of network providers/pharmacies; they are as follows:

1. Drugs may be covered for an illness while members are travelling outside of the plan’s service area and where there are no network pharmacies.
2. Part D vaccines administered in a clinic or hospital setting which are considered out of network.

In the event you are unable to use an in network pharmacy and none of the above scenarios would apply; you must have prior authorization (advance approval) from our plan to get prescriptions from an out-of-network pharmacy provider. If you pay out-of-pocket for a prescription and you feel we should cover this expense, please contact us or send the bill to us for payment review. You can find more detailed information regarding how this is done in your Evidence of Coverage.

Interpreter Services

Interpreter Services Information can be found here. We have interpreter services available to answer questions about our health and drug plan. To get an interpreter, call us at (800) 394-5566. This is a free service.

Contact Information

If you have questions or require language assistance, please call Customer Service at (800) 394-5566. For people who are deaf, hard of hearing, or speech impaired please call TTY/TDD 711 or toll free (800) 877-8973. This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. You may also call through a video relay service company of your choice. Interpreter services are provided free of charge to you. A customer service representative is available to assist you Monday through Friday from 8 a.m. to 8 p.m. From October 1 through February 14 we are also available to assist you on Saturdays and Sundays from 8 a.m. to 8 p.m.


Senior Preferred is an HMO plan with a Medicare contract. Enrollment in Senior Preferred depends on contract renewal. Medicare Advantage & Part D contracts are reviewed annually by The Centers for Medicare and Medicaid Services to determine renewal status of the plan. You must continue to pay your Medicare Part B premium. The benefit information provided herein is a brief summary, not a comprehensive description of benefits.  Members must use plan providers except in emergency or urgent care situations or for out-of-area renal dialysis. For more information contact the plan.

Senior Preferred does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations.

This web page was updated on February 12, 2018.