2012 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
Rocky Mountain Standard Plan + Rx (Cost) (H0602-020-0) Benefit Details | ||||||
This plan is available in Bent County, CO Click on a letter below to view the Rocky Mountain Standard Plan + Rx (Cost) 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: : | $10.00 | $10.00 | n/a | $30.00 | $30.00 | $25.00 |
Tier 2: : | $10.00 | $10.00 | n/a | $30.00 | $30.00 | $25.00 |
Tier 3: : | $40.00 | $40.00 | n/a | $120.00 | $120.00 | $100.00 |
Tier 4: : | $60.00 | $60.00 | n/a | $180.00 | $180.00 | $150.00 |
Tier 5: : | 33% | 33% | n/a | 33% | 33% | 33% |
Coverage Gap (Donut Hole) Phase Cost Sharing Plan offers no Gap Coverage -- 14% Generic and 50% Brand Donut Hole Discount applies | ||||||
All Formulary Generic Drugs: | 86% | 86% | 86% | 86% | 86% | 86% |
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 $2.60 | The greater of 5% or $2.60 | ||||
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): | The greater of 5% or $6.50 | The greater of 5% or $6.50 | ||||
Go to the Rocky Mountain Standard Plan + Rx (Cost) 2012 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 |