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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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First+Plus Advantage (PPO) (H4011-010-0) Benefit Details 
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| This plan is available in Manati County, PR Monthly Premium: $49.50 Rx Deductible: $0 Initial Coverage Limit: $3,310 Click on a letter below to view the First+Plus Advantage (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: | $6.00 | $6.00 | n/a | $18.00 | $18.00 | $12.00 |
| Tier 2: Generic: | $14.00 | $14.00 | n/a | $42.00 | $42.00 | $28.00 |
| Tier 3: Preferred Brand: | $40.00 | $40.00 | n/a | $120.00 | $120.00 | $80.00 |
| Tier 4: Non-Preferred Brand: | $65.00 | $65.00 | n/a | $195.00 | $195.00 | $130.00 |
| Tier 5: Specialty Tier: | 33% | 33% | n/a | 33% | 33% | 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: Preferred Generic: | $6.00(P) | $6.00(P) | n/a | $18.00(P) | $18.00(P) | $12.00(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: | $40.00(P) | $40.00(P) | n/a | $120.00(P) | $120.00(P) | $80.00(P) |
| Tier 4: Non-Preferred Brand: | $65.00(P) | $65.00(P) | n/a | $195.00(P) | $195.00(P) | $130.00(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 First+Plus Advantage (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 | ||||||