2015 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
PriorityMedicare Select (PPO) (H4875-017-5) Benefit Details | ||||||
This plan is available in ARENAC County, MI Monthly Premium: $178.00 Rx Deductible: $0 Initial Coverage Limit: $2,960 Click on a letter below to view the PriorityMedicare Select (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: | $4.00 | $4.00 | $4.00 | $12.00 | $12.00 | $10.00 |
Tier 2: Non-Preferred Generic: | $9.00 | $9.00 | $9.00 | $27.00 | $27.00 | $22.50 |
Tier 3: Preferred Brand: | $40.00 | $40.00 | $40.00 | $120.00 | $120.00 | $100.00 |
Tier 4: Non-Preferred Brand: | $85.00 | $85.00 | $85.00 | $255.00 | $255.00 | $212.50 |
Tier 5: Specialty Tier: | 33% | 33% | 33% | n/a | n/a | n/a |
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 PriorityMedicare Select (PPO) 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 |