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2016 Medicare Advantage Plan Prescription Drug Cost-Sharing Details

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2016 Medicare Advantage Prescription Drug
Formulary (Drug List) Cost-Sharing Details
Optimum Emerald Partial (HMO SNP) (H5594-016-0)
Benefit Details        
This plan is available in Brevard County, FL

Monthly Premium: $28.00
Rx Deductible: $360
Initial Coverage Limit: $3,310


Click on a letter below to view the
Optimum Emerald Partial (HMO SNP) Formulary
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  30-Day Supply
Cost-Sharing
90-Day Supply
Cost-Sharing
Preferred Pharmacy Standard Pharmacy Mail- Order* Preferred Pharmacy Standard Pharmacy Mail- Order*
Initial Deductible Phase Cost Sharing
Tier 1: Generic: $0.00(E) $0.00(E) $0.00(E) $0.00(E) $0.00(E) $0.00(E)
Tier 2: Preferred Brand: 100% 100% 100% 100% 100% 100%
Tier 3: Non-Preferred Brand: 100% 100% 100% 100% 100% 100%
Tier 4: Specialty Tier: 100% 100% 100% 100% 100% 100%
Initial Coverage Phase Cost-Sharing
Tier 1: Generic: $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
Tier 2: Preferred Brand: $45.00 $45.00 $45.00 $135.00 $135.00 $135.00
Tier 3: Non-Preferred Brand: $95.00 $95.00 $95.00 $285.00 $285.00 $285.00
Tier 4: Specialty Tier: 25% 25% 25% 25% 25% 25%
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 Optimum Emerald Partial (HMO SNP) 2016 Formulary Browser by choosing a letter below:
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