2016 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
Medicare HMO Blue FlexRx (HMO-POS) (H2261-021-0) Benefit Details | ||||||
This plan is available in Bristol County, MA Monthly Premium: $99.00 Rx Deductible: $260 Initial Coverage Limit: $3,310 Click on a letter below to view the Medicare HMO Blue FlexRx (HMO-POS) 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: : | $2.00(E) | $2.00(E) | $2.00(E) | $6.00(E) | $6.00(E) | $2.00(E) |
Tier 2: : | $6.00(E) | $6.00(E) | $6.00(E) | $18.00(E) | $18.00(E) | $12.00(E) |
Tier 3: : | 100% | 100% | 100% | 100% | 100% | 100% |
Tier 4: : | 100% | 100% | 100% | 100% | 100% | 100% |
Tier 5: : | 100% | 100% | 100% | 100% | 100% | 100% |
Initial Coverage Phase Cost-Sharing | ||||||
Tier 1: : | $2.00 | $2.00 | $2.00 | $6.00 | $6.00 | $2.00 |
Tier 2: : | $6.00 | $6.00 | $6.00 | $18.00 | $18.00 | $12.00 |
Tier 3: : | $45.00 | $45.00 | $45.00 | $135.00 | $135.00 | $90.00 |
Tier 4: : | $95.00 | $95.00 | $95.00 | $285.00 | $285.00 | $190.00 |
Tier 5: : | 25% | 25% | 25% | 25% | 25% | 25% |
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 Medicare HMO Blue FlexRx (HMO-POS) 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 |