2016 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
Freedom Blue PPO Standard (PPO) (H5106-013-0) Benefit Details ![]() ![]() ![]() | ||||||
This plan is available in Barbour County, WV Monthly Premium: $212.50 Rx Deductible: $0 Initial Coverage Limit: $3,310 Click on a letter below to view the Freedom Blue PPO Standard (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* | |
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: Preferred Generic: | $3.00 | $3.00 | n/a | $9.00 | $9.00 | $7.50 |
Tier 2: Generic: | $15.00 | $15.00 | n/a | $45.00 | $45.00 | $37.50 |
Tier 3: Preferred Brand: | $44.00 | $44.00 | n/a | $132.00 | $132.00 | $110.00 |
Tier 4: Non-Preferred Brand: | 45% | 45% | n/a | 45% | 45% | 45% |
Tier 5: Specialty Tier: | 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 Freedom Blue PPO Standard (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 |