2012 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
HumanaChoice H6609-019 (PPO) (H6609-019-0) Benefit Details | ||||||
This plan is available in Kingsbury County, SD Click on a letter below to view the HumanaChoice H6609-019 (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 | ||||||
This Plan Uses Lower Cost-Sharing for Preferred Pharmacies | ||||||
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: : | $1.00 | $10.00 | $0.00 | $3.00 | $30.00 | $0.00 |
Tier 2: : | $5.00 | $12.00 | $0.00 | $15.00 | $36.00 | $0.00 |
Tier 3: : | 100% | 100% | 100% | 100% | 100% | 100% |
Tier 4: : | 100% | 100% | 100% | 100% | 100% | 100% |
Initial Coverage Phase Cost-Sharing | ||||||
Tier 1: : | $1.00 | $10.00 | $0.00 | $3.00 | $30.00 | $0.00 |
Tier 2: : | $5.00 | $12.00 | $0.00 | $15.00 | $36.00 | $0.00 |
Tier 3: : | 20% | 30% | 20% | 20% | 30% | 20% |
Tier 4: : | 30% | 40% | 30% | 30% | 40% | 30% |
Coverage Gap (Donut Hole) Phase Cost Sharing 14% Generic and 50% Brand Donut Hole Discount applies to all drugs even those with coverage in the gap | ||||||
Tier 1: : | ||||||
Tier 2: : | ||||||
Tier 3: : | ||||||
Tier 4: : | ||||||
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 | ||||
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 HumanaChoice H6609-019 (PPO) 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 |