2014 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
Medicare Blue (PPO) (H4209-003-0) Benefit Details | ||||||
This plan is available in ALLENDALE County, SC Monthly Premium: $38.50 Rx Deductible: $195 Initial Coverage Limit: $2,850 Click on a letter below to view the Medicare Blue (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* | |
Initial Deductible Phase Cost Sharing | ||||||
Tier 1: Preferred Generic: | $2.00(E) | $2.00(E) | $2.00(E) | $6.00(E) | $6.00(E) | $4.00(E) |
Tier 2: Non-Preferred Generic: | $15.00(E) | $15.00(E) | $15.00(E) | $45.00(E) | $45.00(E) | $37.50(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: | $2.00 | $2.00 | $2.00 | $6.00 | $6.00 | $4.00 |
Tier 2: Non-Preferred Generic: | $15.00 | $15.00 | $15.00 | $45.00 | $45.00 | $37.50 |
Tier 3: Preferred Brand: | $45.00 | $45.00 | $45.00 | $135.00 | $135.00 | $112.50 |
Tier 4: Non-Preferred Brand: | $85.00 | $85.00 | $85.00 | $255.00 | $255.00 | $212.50 |
Tier 5: Specialty Tier: | 27% | 27% | 27% | 27% | 27% | 27% |
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: | $2.00(A) | $2.00(A) | $2.00(A) | $6.00(A) | $6.00(A) | $4.00(A) |
Tier 2: Non-Preferred Generic: | $15.00(A) | $15.00(A) | $15.00(A) | $45.00(A) | $45.00(A) | $37.50(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. (E) Drugs on this tier are excluded from the Initial Deductible and do not count toward meeting the deductible. (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 Medicare Blue (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 |