2014 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
Rocky Mountain Green Plan + Rx (Cost) (H0602-043-0) Benefit Details | ||||||
This plan is available in JACKSON County, CO Monthly Premium: $69.40 Rx Deductible: $120 Initial Coverage Limit: $2,850 Click on a letter below to view the Rocky Mountain Green Plan + Rx (Cost) 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: Preferred Generic: | $3.00(E) | $3.00(E) | n/a(E) | $7.50(E) | $9.00(E) | $7.50(E) |
Tier 2: Non-Preferred Generic: | $25.00(E) | $25.00(E) | n/a(E) | $62.50(E) | $75.00(E) | $62.50(E) |
Tier 3: Preferred Brand: | 100% | 100% | 100% | 100% | 100% | 100% |
Tier 4: Non-Preferred Brand: | 100% | 100% | 100% | 100% | 100% | 100% |
Tier 5: Specialty Tier: | 100% | 100% | 100% | 100% | 100% | 100% |
Initial Coverage Phase Cost-Sharing | ||||||
Tier 1: Preferred Generic: | $3.00 | $3.00 | n/a | $7.50 | $9.00 | $7.50 |
Tier 2: Non-Preferred Generic: | $25.00 | $25.00 | n/a | $62.50 | $75.00 | $62.50 |
Tier 3: Preferred Brand: | $40.00 | $40.00 | n/a | $100.00 | $120.00 | $100.00 |
Tier 4: Non-Preferred Brand: | $80.00 | $80.00 | n/a | $200.00 | $240.00 | $200.00 |
Tier 5: Specialty Tier: | 30% | 30% | 30% | n/a | n/a | n/a |
Coverage Gap (Donut Hole) Phase Cost Sharing Plan offers no Gap Coverage -- 28% 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 $2.55 | The greater of 5% or $2.55 | ||||
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): | The greater of 5% or $6.35 | The greater of 5% or $6.35 | ||||
Notes: *The mail-order cost-sharing is the plan’s "preferred" mail-order cost-sharing. (E) Drugs on this tier are excluded from the Initial Deductible and do not count toward meeting the deductible. | ||||||
Go to the Rocky Mountain Green Plan + Rx (Cost) 2014 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 |