2014 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
First+Plus Advantage Plus (PPO) (H4011-003-0) Benefit Details | ||||||
This plan is available in ADJUNTAS County, PR Monthly Premium: $0.00 Rx Deductible: $0 Initial Coverage Limit: $2,850 Click on a letter below to view the First+Plus Advantage Plus (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 |
|||||
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: | $6.00 | $6.00 | n/a | $18.00 | $18.00 | $12.00 |
Tier 2: Non-Preferred Generic: | $12.00 | $12.00 | n/a | $36.00 | $36.00 | $24.00 |
Tier 3: Preferred Brand: | $35.00 | $35.00 | n/a | $105.00 | $105.00 | $70.00 |
Tier 4: Non-Preferred Brand: | $55.00 | $55.00 | n/a | $165.00 | $165.00 | $110.00 |
Tier 5: Specialty Tier: | 25% | 25% | n/a | 25% | 25% | n/a |
Coverage Gap (Donut Hole) Phase Cost Sharing 28% Generic and 52.5% Brand Donut Hole Discount applies to all drugs even those with coverage in the gap | ||||||
Tier 1: Preferred Generic: | $6.00(A) | $6.00(A) | n/a | $18.00(A) | $18.00(A) | $12.00(A) |
Tier 2: Non-Preferred Generic: | $12.00(A) | $12.00(A) | n/a | $36.00(A) | $36.00(A) | $24.00(A) |
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. (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 First+Plus Advantage Plus (PPO) 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 |