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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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Anthem MediBlue Access (PPO) (H6786-002-0) Benefit Details 
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| This plan is available in Cumberland County, ME Monthly Premium: $96.00 Rx Deductible: $310 Initial Coverage Limit: $3,310 Click on a letter below to view the Anthem MediBlue Access (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* | |
| Initial Deductible Phase Cost Sharing | ||||||
| Tier 1: Preferred Generic: | $3.00(E) | $8.00(E) | $3.00(E) | $9.00(E) | $24.00(E) | $9.00(E) |
| Tier 2: Generic: | 100% | 100% | 100% | 100% | 100% | 100% |
| Tier 3: Preferred Brand: | 100% | 100% | 100% | 100% | 100% | 100% |
| Tier 4: Non-Preferred Brand: | 100% | 100% | 100% | 100% | 100% | 100% |
| Tier 5: Specialty Tier: | 100% | 100% | 100% | 100% | 100% | 100% |
| Tier 6: Select Care Drugs: | $0.00(E) | $0.00(E) | $0.00(E) | $0.00(E) | $0.00(E) | $0.00(E) |
| Initial Coverage Phase Cost-Sharing | ||||||
| Tier 1: Preferred Generic: | $3.00 | $8.00 | $3.00 | $9.00 | $24.00 | $9.00 |
| Tier 2: Generic: | $10.00 | $15.00 | $10.00 | $30.00 | $45.00 | $30.00 |
| Tier 3: Preferred Brand: | $42.00 | $47.00 | $42.00 | $126.00 | $141.00 | $126.00 |
| Tier 4: Non-Preferred Brand: | $95.00 | $100.00 | $95.00 | $285.00 | $300.00 | $285.00 |
| Tier 5: Specialty Tier: | 26% | 26% | 26% | n/a | n/a | n/a |
| Tier 6: Select Care Drugs: | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| 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 Anthem MediBlue Access (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 | ||||||