2014 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
SCAN Connections at Home (HMO SNP) (H5425-029-0) Benefit Details | ||||||
This plan is available in LOS ANGELES County, CA Monthly Premium: $28.10 Rx Deductible: $310 Initial Coverage Limit: $2,850 Click on a letter below to view the SCAN Connections at Home (HMO SNP) 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 | ||||||
All Formulary Drug Tiers: | 100% | 100% | 100% | 100% | 100% | 100% |
Initial Coverage Phase Cost-Sharing | ||||||
Tier 1: : | n/a | n/a | n/a | n/a | n/a | n/a |
Tier 2: : | n/a | n/a | n/a | n/a | n/a | n/a |
Tier 3: : | n/a | n/a | n/a | n/a | n/a | n/a |
Tier 4: : | n/a | n/a | n/a | n/a | n/a | n/a |
Tier 5: : | n/a | n/a | n/a | n/a | n/a | n/a |
Tier 6: : | n/a | n/a | n/a | 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 | ||||
Go to the SCAN Connections at Home (HMO SNP) 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 |