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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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Advantra Option 1 (HMO-POS) (H2663-006-0) Benefit Details 
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| This plan is available in Randolph County, IL Monthly Premium: $39.00 Rx Deductible: $0 Initial Coverage Limit: $3,310 Click on a letter below to view the Advantra Option 1 (HMO-POS) 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: | $2.00 | $7.00 | $7.00 | $6.00 | $21.00 | $21.00 |
| Tier 2: Generic: | $7.00 | $12.00 | $12.00 | $21.00 | $36.00 | $36.00 |
| Tier 3: Preferred Brand: | $47.00 | $47.00 | $47.00 | $141.00 | $141.00 | $141.00 |
| Tier 4: Non-Preferred Brand: | 50% | 50% | 50% | 50% | 50% | 50% |
| Tier 5: Specialty Tier: | 33% | 33% | 33% | 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 Advantra Option 1 (HMO-POS) 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 | ||||||