2015 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
SeniorCare Sr VIP - Value Rx (Cost) (H4564-019-0) Benefit Details | ||||||
This plan is available in SCHLEICHER County, TX Monthly Premium: $199.70 Rx Deductible: $0 Initial Coverage Limit: $2,960 Click on a letter below to view the SeniorCare Sr VIP - Value 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* | |
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: | $10.00 | $10.00 | $10.00 | $30.00 | $30.00 | $20.00 |
Tier 2: Non-Preferred Generic: | $25.00 | $25.00 | $25.00 | $75.00 | $75.00 | $50.00 |
Tier 3: Preferred Brand: | $45.00 | $45.00 | $45.00 | $135.00 | $135.00 | $90.00 |
Tier 4: Non-Preferred Brand: | $95.00 | $95.00 | $95.00 | $285.00 | $285.00 | $190.00 |
Tier 5: Specialty Tier: | 33% | 33% | 33% | 33% | 33% | 33% |
Coverage Gap (Donut Hole) Phase Cost Sharing Plan offers no Gap Coverage -- 35% Generic and 55% Brand Donut Hole Discount applies | ||||||
All Formulary Generic Drugs: | 65% | 65% | 65% | 65% | 65% | 65% |
All Formulary Brand-Name Drugs: | 45% | 45% | 45% | 45% | 45% | 45% |
Catastrophic Coverage Phase Cost Sharing | ||||||
Generic & Preferred Multi-Source Drugs: | The greater of 5% or $2.65 | The greater of 5% or $2.65 | ||||
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): | The greater of 5% or $6.60 | The greater of 5% or $6.60 | ||||
Go to the SeniorCare Sr VIP - Value Rx (Cost) 2015 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 |