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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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NetworkCares (PPO SNP) (H5215-007-0) Benefit Details 
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| This plan is available in Brown County, WI Monthly Premium: $37.70 Rx Deductible: $120 Initial Coverage Limit: $3,310 Click on a letter below to view the NetworkCares (PPO SNP) 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: | $1.00 | $3.00 | $1.00 | $3.00 | $8.00 | $3.00 |
| Tier 2: Generic: | $13.00 | $18.00 | $13.00 | $30.00 | $35.00 | $30.00 |
| Tier 3: Preferred Brand: | $42.00 | $45.00 | $42.00 | $120.00 | $130.00 | $120.00 |
| Tier 4: Non-Preferred Brand: | $80.00 | $86.00 | $80.00 | $212.00 | $225.00 | $212.00 |
| Tier 5: Specialty Tier: | 30% | 30% | 30% | n/a | n/a | n/a |
| 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 | ||||
| Go to the NetworkCares (PPO SNP) 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 | ||||||