2011 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
Presbyterian MediCare PPO Plan 2 with Rx (PPO) (H3206-001-0) Benefit Details | ||||||
This plan is available in Sierra County, NM Click on a letter below to view the Presbyterian MediCare PPO Plan 2 with Rx (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: : | $5.00 | $5.00 | n/a | $15.00 | $15.00 | $10.00 |
Tier 2: : | $40.00 | $40.00 | n/a | $120.00 | $120.00 | $100.00 |
Tier 3: : | $75.00 | $75.00 | n/a | $225.00 | $225.00 | $225.00 |
Tier 4: : | 30% | 30% | n/a | n/a | n/a | n/a |
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 Presbyterian MediCare PPO Plan 2 with Rx (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 |