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2015 Medicare Advantage Plan Prescription Drug Cost-Sharing Details
| 2015 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
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Health Alliance Medicare HMO 40 Rx (HMO) (H1463-010-0) Benefit Details 
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| This plan is available in JOHNSON County, IL Monthly Premium: $69.00 Rx Deductible: $260 Initial Coverage Limit: $2,960 Click on a letter below to view the Health Alliance Medicare HMO 40 Rx (HMO) 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* | |
| Initial Deductible Phase Cost Sharing | ||||||
| Tier 1: Preferred Generic: | $0.00(E) | $10.00(E) | $10.00(E) | $0.00(E) | $30.00(E) | $30.00(E) |
| Tier 2: Non-Preferred Generic: | $33.00(E) | $33.00(E) | $33.00(E) | $66.00(E) | $99.00(E) | $99.00(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: | 100% | 100% | 100% | 100% | 100% | 100% |
| Initial Coverage Phase Cost-Sharing | ||||||
| Tier 1: Preferred Generic: | $0.00 | $10.00 | $10.00 | $0.00 | $30.00 | $30.00 |
| Tier 2: Non-Preferred Generic: | $33.00 | $33.00 | $33.00 | $66.00 | $99.00 | $99.00 |
| Tier 3: Preferred Brand: | $45.00 | $45.00 | $45.00 | $90.00 | $135.00 | $135.00 |
| Tier 4: Non-Preferred Brand: | $95.00 | $95.00 | $95.00 | $190.00 | $285.00 | $285.00 |
| Tier 5: Specialty Tier: | 26% | 26% | 26% | 26% | 26% | 26% |
| 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 Health Alliance Medicare HMO 40 Rx (HMO) 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 | ||||||