2016 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
Blue Shield 65 Plus Choice Plan (HMO) (H0504-021-0) Benefit Details | ||||||
This plan is available in LOS ANGELES County, CA Monthly Premium: $0.00 Rx Deductible: $0 Initial Coverage Limit: $3,310 Click on a letter below to view the Blue Shield 65 Plus Choice Plan (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 | ||||||
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: : | $0.00 | $7.00 | n/a | $0.00 | $21.00 | $0.00 |
Tier 2: : | $3.00 | $10.00 | n/a | $6.00 | $30.00 | $6.00 |
Tier 3: : | $30.00 | $37.00 | n/a | $60.00 | $111.00 | $60.00 |
Tier 4: : | $65.00 | $72.00 | n/a | $130.00 | $216.00 | $130.00 |
Tier 5: : | 25% | 25% | n/a | 25% | 25% | 25% |
Tier 6: : | 33% | 33% | 33% | n/a | n/a | n/a |
Coverage Gap (Donut Hole) Phase Cost Sharing 42% Generic and 55% Brand Donut Hole Discount applies to all drugs even those with coverage in the gap | ||||||
Tier 1: : | $0.00(A) | $7.00(A) | n/a | $0.00(A) | $21.00(A) | $0.00(A) |
Tier 2: : | $3.00(A) | $10.00(A) | n/a | $6.00(A) | $30.00(A) | $6.00(A) |
Tier 3: : | $30.00(P) | $37.00(P) | n/a | $60.00(P) | $111.00(P) | $60.00(P) |
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. (A) Coverage Gap cost-sharing applies to all drugs on the designated tier. Drugs that are covered in the coverage gap also receive the donut hole discount. (P) Coverage Gap cost-sharing applies to only some of drugs on the designated drug tier. Drugs that are covered in the coverage gap also receive the donut hole discount. | ||||||
Go to the Blue Shield 65 Plus Choice Plan (HMO) 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 |