2012 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
WindsorSterling Gold Access Plan (PFFS) (H5006-017-13) Benefit Details | ||||||
This plan is available in SMITH County, KS Click on a letter below to view the WindsorSterling Gold Access Plan (PFFS) 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* | |
Initial Deductible Phase Cost Sharing | ||||||
Tier 1: : | $5.00 | $5.00 | $5.00 | $15.00 | $15.00 | $15.00 |
Tier 2: : | $15.00 | $15.00 | $15.00 | $45.00 | $45.00 | $45.00 |
Tier 3: : | 100% | 100% | 100% | 100% | 100% | 100% |
Tier 4: : | 100% | 100% | 100% | 100% | 100% | 100% |
Tier 5: : | 100% | 100% | 100% | 100% | 100% | 100% |
Initial Coverage Phase Cost-Sharing | ||||||
Tier 1: : | $5.00 | $5.00 | $5.00 | $15.00 | $15.00 | $15.00 |
Tier 2: : | $15.00 | $15.00 | $15.00 | $45.00 | $45.00 | $45.00 |
Tier 3: : | $34.00 | $34.00 | $34.00 | $102.00 | $102.00 | $102.00 |
Tier 4: : | $84.00 | $84.00 | $84.00 | $252.00 | $252.00 | $252.00 |
Tier 5: : | 30% | 30% | 30% | 30% | 30% | 30% |
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 WindsorSterling Gold Access Plan (PFFS) 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 |