2014 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
HumanaChoice H4520-022 (PPO) (H4520-022-0) Benefit Details | ||||||
This plan is available in CALDWELL County, TX Monthly Premium: $114.00 Rx Deductible: $260 Initial Coverage Limit: $2,850 Click on a letter below to view the HumanaChoice H4520-022 (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 |
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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: | $8.00(E) | $8.00(E) | $8.00(E) | $24.00(E) | $24.00(E) | $0.00(E) |
Tier 2: Non-Preferred Generic: | $15.00(E) | $15.00(E) | $15.00(E) | $45.00(E) | $45.00(E) | $0.00(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: | $8.00 | $8.00 | $8.00 | $24.00 | $24.00 | $0.00 |
Tier 2: Non-Preferred Generic: | $15.00 | $15.00 | $15.00 | $45.00 | $45.00 | $0.00 |
Tier 3: Preferred Brand: | $42.00 | $42.00 | $42.00 | $126.00 | $126.00 | $116.00 |
Tier 4: Non-Preferred Brand: | $85.00 | $85.00 | $85.00 | $255.00 | $255.00 | $245.00 |
Tier 5: Specialty Tier: | 26% | 26% | 26% | 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 HumanaChoice H4520-022 (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 |