2011 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
True Blue Rx Option I (HMO) (H1350-001-0) Benefit Details | ||||||
This plan is available in Minidoka County, ID Click on a letter below to view the True Blue Rx Option I (HMO) Formulary A B C D E F G H I J K L M N O P Q R S T U V W X Y Z 0-9 | ||||||
30-Day Supply Cost-Sharing |
90-Day Supply Cost-Sharing |
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Preferred Pharmacy | Standard Pharmacy | Mail- Order* | Preferred Pharmacy | Standard Pharmacy | Mail- Order* | |
This plan does not have an Initial Deductible: | n/a | n/a | n/a | n/a | n/a | n/a |
Initial Coverage Phase Cost-Sharing | ||||||
Tier 1: : | $6.00 | $6.00 | $6.00 | $18.00 | $18.00 | $18.00 |
Tier 2: : | $31.00 | $31.00 | $31.00 | $93.00 | $93.00 | $93.00 |
Tier 3: : | $41.00 | $41.00 | $41.00 | $123.00 | $123.00 | $123.00 |
Tier 4: : | 25% | 25% | 25% | 25% | 25% | 25% |
Coverage Gap (Donut Hole) Phase Cost Sharing 7% Generic and 50% Brand Donut Hole Discount applies to all drugs even those with coverage in the gap | ||||||
Tier 1: : | ||||||
All Formulary Generic Drugs: | 93% | 93% | 93% | 93% | 93% | 93% |
All Formulary Brand-Name Drugs: | 50% | 50% | 50% | 50% | 50% | 50% |
Catastrophic Coverage Phase Cost Sharing | ||||||
Generic & Preferred Multi-Source Drugs: | The greater of 5% or $2.50 | The greater of 5% or $2.50 | ||||
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): | The greater of 5% or $6.30 | The greater of 5% or $6.30 | ||||
Notes: *The mail-order cost-sharing is the plan’s "preferred" mail-order cost-sharing. (A) Coverage Gap cost-sharing applies to all drugs on the designated tier. Drugs that are covered in the coverage gap also receive the donut hole discount. (P) Coverage Gap cost-sharing applies to only some of drugs on the designated drug tier. Drugs that are covered in the coverage gap also receive the donut hole discount. | ||||||
Go to the True Blue Rx Option I (HMO) 2011 Formulary Browser by choosing a letter below: A B C D E F G H I J K L M N O P Q R S T U V W X Y Z 0-9 |