2016 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
PriorityMedicare Select (PPO) (H4875-017-3) Benefit Details | ||||||
This plan is available in Grand Traverse County, MI Monthly Premium: $160.00 Rx Deductible: $0 Initial Coverage Limit: $3,310 Click on a letter below to view the PriorityMedicare Select (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 |
|||||
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: : | $4.00 | $4.00 | $4.00 | $12.00 | $12.00 | $0.00 |
Tier 2: : | $9.00 | $9.00 | $9.00 | $27.00 | $27.00 | $0.00 |
Tier 3: : | $40.00 | $40.00 | $40.00 | $120.00 | $120.00 | $100.00 |
Tier 4: : | $85.00 | $85.00 | $85.00 | $255.00 | $255.00 | $212.50 |
Tier 5: : | 33% | 33% | 33% | n/a | n/a | n/a |
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 | ||||
Go to the PriorityMedicare Select (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 |