2015 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
Care Improvement Plus Medicare Advantage (Regional PPO) (R9896-012-0) Benefit Details | ||||||
This plan is available in Statewide County, GA Monthly Premium: $27.80 Rx Deductible: $295 Initial Coverage Limit: $2,960 Click on a letter below to view the Care Improvement Plus Medicare Advantage (Regional 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: | $3.00(E) | $3.00(E) | n/a(E) | $9.00(E) | $9.00(E) | $6.00(E) |
Tier 2: Non-Preferred Generic: | $13.00(E) | $13.00(E) | n/a(E) | $39.00(E) | $39.00(E) | $26.00(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: | 33%(E) | 33%(E) | n/a(E) | 33%(E) | 33%(E) | 33%(E) |
Initial Coverage Phase Cost-Sharing | ||||||
Tier 1: Preferred Generic: | $3.00 | $3.00 | n/a | $9.00 | $9.00 | $6.00 |
Tier 2: Non-Preferred Generic: | $13.00 | $13.00 | n/a | $39.00 | $39.00 | $26.00 |
Tier 3: Preferred Brand: | $45.00 | $45.00 | n/a | $135.00 | $135.00 | $125.00 |
Tier 4: Non-Preferred Brand: | $95.00 | $95.00 | n/a | $285.00 | $285.00 | $275.00 |
Tier 5: Specialty Tier: | 33% | 33% | n/a | 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 | ||||
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 Care Improvement Plus Medicare Advantage (Regional 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 |