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2016 Medicare Advantage Plan Prescription Drug Cost-Sharing Details
| 2016 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
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MMM- Unico Extra (HMO) (H4003-015-0) Benefit Details 
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| This plan is available in Aguada County, PR Monthly Premium: $0.00 Rx Deductible: $90 Initial Coverage Limit: $3,310 Click on a letter below to view the MMM- Unico Extra (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* | |
| Initial Deductible Phase Cost Sharing | ||||||
| All Formulary Drug Tiers: | 100% | 100% | 100% | 100% | 100% | 100% |
| Initial Coverage Phase Cost-Sharing | ||||||
| Tier 1: Preferred Generic: | $4.00 | $4.00 | n/a | $12.00 | $12.00 | $8.00 |
| Tier 2: Generic: | $14.00 | $14.00 | n/a | $42.00 | $42.00 | $28.00 |
| Tier 3: Preferred Brand: | $25.00 | $25.00 | n/a | $75.00 | $75.00 | $50.00 |
| Tier 4: Non-Preferred Brand: | $60.00 | $60.00 | n/a | $180.00 | $180.00 | $120.00 |
| Tier 5: Specialty Tier: | 31% | 31% | n/a | 31% | 31% | 31% |
| 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: Preferred Generic: | $4.00(P) | $4.00(P) | n/a | $12.00(P) | $12.00(P) | $8.00(P) |
| Tier 2: Generic: | $14.00(P) | $14.00(P) | n/a | $42.00(P) | $42.00(P) | $28.00(P) |
| Tier 3: Preferred Brand: | $25.00(P) | $25.00(P) | n/a | $75.00(P) | $75.00(P) | $50.00(P) |
| Tier 4: Non-Preferred Brand: | $60.00(P) | $60.00(P) | n/a | $180.00(P) | $180.00(P) | $120.00(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 MMM- Unico Extra (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 | ||||||