2013 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
Windsor Medicare Extra Emerald Plan (HMO) (H5698-061-0) Benefit Details ![]() ![]() ![]() | ||||||
This plan is available in ADAMS County, MS Click on a letter below to view the Windsor Medicare Extra Emerald Plan (HMO) 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: Preferred Generic: | $3.00 | $3.00 | $3.00 | $9.00 | $9.00 | $9.00 |
Tier 2: Non-Preferred Generic: | $10.00 | $10.00 | $10.00 | $30.00 | $30.00 | $30.00 |
Tier 3: Preferred Brand: | $45.00 | $45.00 | $45.00 | $135.00 | $135.00 | $135.00 |
Tier 4: Non-Preferred Brand: | $70.00 | $70.00 | $70.00 | $210.00 | $210.00 | $210.00 |
Tier 5: Specialty Tier: | 33% | 33% | 33% | 33% | 33% | 33% |
Coverage Gap (Donut Hole) Phase Cost Sharing 21% Generic and 52.5% Brand Donut Hole Discount applies to all drugs even those with coverage in the gap | ||||||
Tier 1: Preferred Generic: | ||||||
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 | ||||
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 Windsor Medicare Extra Emerald Plan (HMO) 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 |