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2013 Medicare Advantage Plan Prescription Drug Cost-Sharing Details
| 2013 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
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Providence Medicare Extra Part B Only + RX (HMO) (H9047-013-0) Benefit Details 
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| This plan is available in WASHINGTON County, OR Click on a letter below to view the Providence Medicare Extra Part B Only + RX (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 | ||||||
| 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* | |
| 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: : | $6.00 | $9.00 | $6.00 | $18.00 | $27.00 | $18.00 |
| Tier 2: : | $11.00 | $15.00 | $11.00 | $33.00 | $45.00 | $33.00 |
| Tier 3: : | $35.00 | $35.00 | $35.00 | $105.00 | $105.00 | $105.00 |
| Tier 4: : | $70.00 | $70.00 | $70.00 | $210.00 | $210.00 | $210.00 |
| Tier 5: : | 33% | 33% | 33% | n/a | n/a | n/a |
| Tier 6: : | 33% | 33% | 33% | n/a | n/a | n/a |
| 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 Providence Medicare Extra Part B Only + RX (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 | ||||||