Medicare Prescription Drug Coverage Information

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Out-of-Pocket Drug Costs

Subsidy Levels	Deductible	Copayment*
Level 1	$0	$5.10 / $12.65
Level 2	$0	$1.60 / $4.90
Level 3	$0	$0 / $0

*Copayment amounts for generic/preferred multi-source and other drugs, respectively. For example, the first amount shown ($5.10) is the copayment for a generic/preferred multi-source drug filled for a member in the LIS Category 1.

Medicare Prescription Payment Plan

The Medicare Prescription Payment Plan is a payment option that works with your current drug coverage to help you manage your out-of-pocket costs for drugs covered by our plan by spreading them across the calendar year (January-December). Anyone with a Medicare drug plan or Medicare health plan with drug coverage (like a Medicare Advantage plan with drug coverage) can use this payment option.

This payment option might help you manage your expenses, but it doesn’t save you money or lower your drug costs. If you’re participating in the Medicare Prescription Payment Plan and stay in the same plan, you don’t need to do anything to continue this option. “Extra Help” from Medicare and help from your SPAP and ADAP, for those who qualify, is more advantageous than participation in this payment option, no matter your income level, and plans with drug coverage must offer this payment option.

To learn more about this payment option, call Member Services at (844) 729-8411, 8 a.m. - 8 p.m. or visit www.medicare.gov.

If you are enrolled in this program, click the button below to make a payment.

Make a Payment

Not enrolled? Sign up for the Medicare Prescription Payment Plan online.

Contra Costa Care Plus Transition Policy

Getting a Temporary Supply

In some cases, we can give you a temporary supply of a drug when the drug isn’t on our Drug List or is limited in some way. This gives you time to talk with your provider about getting a different drug or to ask us to cover the drug.

To get a temporary supply of a drug, you must meet the two rules below:

1. The drug you’ve been taking:

is no longer on our Drug List or
was never on our Drug List or
is now limited in some way.

2. You must be in one of these situations:

You’re new to our plan.
- We cover a temporary supply of your drug during the first 90 days of the calendar year.
- This temporary supply is for up to 30 days.
- If your prescription is written for fewer days, we allow multiple refills to provide up to a maximum of 30 days of medication. You must fill the prescription at a network pharmacy.
- Long-term care pharmacies may provide your drug in small amounts at a time to prevent waste.
You’ve been in our plan for more than 90 days, live in a long-term care facility, and need a supply right away.
- We cover one 31-day supply, or less if your prescription is written for fewer days. This is in addition to the temporary supply above.
- If you are a current member with changes to your level of care, we will allow you to refill your prescription until we have provided you with a 31-day transition supply, unless you have a prescription written for fewer days.

Medication Therapy Management Program

Our plan has a program to help members with complex health needs. In such cases, you may be eligible to get services, at no cost to you, through a medication therapy management (MTM) program. This program is voluntary and free. This program helps you and your provider make sure that your medications are working to improve your health. If you qualify for the program, a pharmacist or other health professional will give you a comprehensive review of all of your medications and talk with you about:

how to get the most benefit from the drugs you take
any concerns you have, like medication costs and drug reactions
how best to take your medications
any questions or problems you have about your prescription and over-the-counter medication

Then, they'll give you:

A written summary of this discussion. The summary has a medication action plan that recommends what you can do for the best use of your medications.
A personal medication list that includes all medications you take, how much you take, and when and why you take them.
Information about safe disposal of prescription medications that are controlled substances.

It’s a good idea to talk to your prescriber about your action plan and medication list.

Take your action plan and medication list to your visit or anytime you talk with your doctors, pharmacists, and other health care providers.
Take your medication list with you if you go to the hospital or emergency room.

MTM programs are voluntary and free to members who qualify. If we have a program that fits your needs, we enroll you in the program and send you information. If you don’t want to be in the program, let us know, and we’ll take you out of it. If you have questions about these programs, contact Member Services at (844) 729-8411 (TTY 711) or your Care Manager.

Pharmacy Materials

List of Covered Drugs (Formulary)
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Step Therapy

Prior Authorization Requirements

Find a Pharmacy

Find Covered Drugs

PerformRx Portal

Contra Costa Health Care Plus Dual Eligible Special Needs Plan (HMO D-SNP) is a health plan that contracts with both Medicare and Medi-Cal to provide enrollees with the benefits of both programs. Limitations and restrictions may apply.

H5119_web01_01_2026_M. Updated November 19, 2025