2016 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
Blue Advantage Complete (PPO) (H0104-012-0) Benefit Details | ||||||
This plan is available in Clarke County, AL Monthly Premium: $75.00 Rx Deductible: $360 Initial Coverage Limit: $3,310 Click on a letter below to view the Blue Advantage Complete (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 |
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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: | $4.00(E) | $4.00(E) | $4.00(E) | $8.00(E) | $12.00(E) | $8.00(E) |
Tier 2: Generic: | $20.00(E) | $20.00(E) | $20.00(E) | $40.00(E) | $60.00(E) | $40.00(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% |
Tier 6: Select Care Drugs: | $2.00(E) | $2.00(E) | $2.00(E) | $4.00(E) | $6.00(E) | $4.00(E) |
Initial Coverage Phase Cost-Sharing | ||||||
Tier 1: Preferred Generic: | $4.00 | $4.00 | $4.00 | $8.00 | $12.00 | $8.00 |
Tier 2: Generic: | $20.00 | $20.00 | $20.00 | $40.00 | $60.00 | $40.00 |
Tier 3: Preferred Brand: | $47.00 | $47.00 | $47.00 | $94.00 | $141.00 | $94.00 |
Tier 4: Non-Preferred Brand: | $100.00 | $100.00 | $100.00 | $200.00 | $300.00 | $200.00 |
Tier 5: Specialty Tier: | 25% | 25% | 25% | 25% | 25% | 25% |
Tier 6: Select Care Drugs: | $2.00 | $2.00 | $2.00 | $4.00 | $6.00 | $4.00 |
Coverage Gap (Donut Hole) Phase Cost Sharing Plan offers no Gap Coverage -- 42% Generic and 55% Brand Donut Hole Discount applies | ||||||
All Formulary Generic Drugs: | 58% | 58% | 58% | 58% | 58% | 58% |
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 $2.95 | The greater of 5% or $2.95 | ||||
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): | The greater of 5% or $7.40 | The greater of 5% or $7.40 | ||||
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 Blue Advantage Complete (PPO) 2016 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 |