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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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SecureCare - Option II (HMO) (H3672-020-0) Benefit Details 
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| This plan is available in Lewis County, WV Monthly Premium: $76.00 Rx Deductible: $0 Initial Coverage Limit: $3,310 Click on a letter below to view the SecureCare - Option II (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* | |
| 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 | $13.00 | n/a | $9.00 | $39.00 | $6.00 |
| Tier 2: Generic: | $10.00 | $20.00 | n/a | $30.00 | $60.00 | $20.00 |
| Tier 3: Preferred Brand: | $35.00 | $45.00 | n/a | $105.00 | $135.00 | $70.00 |
| Tier 4: Non-Preferred Brand: | $85.00 | $95.00 | n/a | $255.00 | $285.00 | $170.00 |
| Tier 5: Specialty Tier: | 33% | 33% | 33% | n/a | n/a | 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: | $3.00(A) | $13.00(A) | n/a | $9.00(A) | $39.00(A) | $6.00(A) |
| 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 SecureCare - Option II (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 | ||||||