2015 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
SeniorBlue - Option 2 (PPO) (H3923-013-0) Benefit Details | ||||||
This plan is available in YORK County, PA Monthly Premium: $72.40 Rx Deductible: $0 Initial Coverage Limit: $2,960 Click on a letter below to view the SeniorBlue - Option 2 (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 | ||||||
This Plan Uses Lower Cost-Sharing for Preferred Pharmacies | ||||||
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: : | $5.00 | $10.00 | $5.00 | $15.00 | $30.00 | $15.00 |
Tier 2: : | $17.00 | $22.00 | $17.00 | $51.00 | $66.00 | $51.00 |
Tier 3: : | $38.00 | $45.00 | $38.00 | $114.00 | $135.00 | $114.00 |
Tier 4: : | $90.00 | $95.00 | $90.00 | $270.00 | $285.00 | $270.00 |
Tier 5: : | 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 SeniorBlue - Option 2 (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 |