2013 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
Freedom Blue PPO Select (PPO) (H3916-024-0) Benefit Details | ||||||
This plan is available in BEDFORD County, PA Click on a letter below to view the Freedom Blue PPO Select (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: Generic: | $9.00 | $9.00 | n/a | $27.00 | $27.00 | $22.50 |
Tier 2: Preferred Brand: | $45.00 | $45.00 | n/a | $135.00 | $135.00 | $112.50 |
Tier 3: Non-Preferred Brand: | $90.00 | $90.00 | n/a | $270.00 | $270.00 | $225.00 |
Tier 4: Specialty Tier: | 33% | 33% | n/a | 33% | 33% | 33% |
Coverage Gap (Donut Hole) Phase Cost Sharing Plan offers no Gap Coverage -- 21% Generic and 52.5% Brand Donut Hole Discount applies | ||||||
All Formulary Generic Drugs: | 79% | 79% | 79% | 79% | 79% | 79% |
All Formulary Brand-Name Drugs: | 47.5% | 47.5% | 47.5% | 47.5% | 47.5% | 47.5% |
Catastrophic Coverage Phase Cost Sharing | ||||||
Generic & Preferred Multi-Source Drugs: | The greater of 5% or $2.65 | The greater of 5% or $2.65 | ||||
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): | The greater of 5% or $6.60 | The greater of 5% or $6.60 | ||||
Go to the Freedom Blue PPO Select (PPO) 2013 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 |