2011 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
Aetna Medicare Premier Plan (PPO) (H5521-012-0) Sanctioned Plan | ||||||
This plan is available in Lehigh County, PA Click on a letter below to view the Aetna Medicare Premier Plan (PPO) 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: Tier 1: Preferred Generic Drugs: | $5.00 | $5.00 | n/a | $15.00 | $15.00 | $10.00 |
Tier 2: Tier 2: Non-Preferred Generic Drugs: | $34.00 | $34.00 | n/a | $102.00 | $102.00 | $68.00 |
Tier 3: Tier 3: Preferred Brand Drugs: | $45.00 | $45.00 | n/a | $135.00 | $135.00 | $90.00 |
Tier 4: Tier 4: Non-Preferred Brand Drugs: | $85.00 | $85.00 | n/a | $255.00 | $255.00 | $170.00 |
Tier 5: Tier 5: Specialty Tier Drugs: | 33% | 33% | n/a | 33% | 33% | 33% |
Coverage Gap (Donut Hole) Phase Cost Sharing Plan offers no Gap Coverage -- 7% Generic and 50% Brand Donut Hole Discount applies | ||||||
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 | ||||
Go to the Aetna Medicare Premier Plan (PPO) 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 |