2017 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
HAP Senior Plus Option 3 (HMO-POS) (H2354-022-0) Benefit Details | ||||||
This plan is available in Arenac County, MI Monthly Premium: $218.00 Rx Deductible: $50 Initial Coverage Limit: $3,700 Click on a letter below to view the HAP Senior Plus Option 3 (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 |
|||||
Preferred Pharmacy | Standard Pharmacy | Mail- Order* | Preferred Pharmacy | Standard Pharmacy | Mail- Order* | |
Initial Deductible Phase Cost Sharing | ||||||
Tier 1: Preferred Generic: | $4.00(E) | $4.00(E) | n/a(E) | $10.00(E) | $10.00(E) | n/a(E) |
Tier 2: Generic: | $10.00(E) | $10.00(E) | n/a(E) | $25.00(E) | $25.00(E) | n/a(E) |
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% |
Initial Coverage Phase Cost-Sharing | ||||||
Tier 1: Preferred Generic: | $4.00 | $4.00 | n/a | $10.00 | $10.00 | n/a |
Tier 2: Generic: | $10.00 | $10.00 | n/a | $25.00 | $25.00 | n/a |
Tier 3: Preferred Brand: | $45.00 | $45.00 | n/a | $112.50 | $112.50 | n/a |
Tier 4: Non-Preferred Brand: | $100.00 | $100.00 | n/a | $250.00 | $250.00 | n/a |
Tier 5: Specialty Tier: | 32% | 32% | n/a | 32% | 32% | n/a |
Coverage Gap (Donut Hole) Phase Cost Sharing 49% Generic and 60% Brand Donut Hole Discount applies to all drugs even those with coverage in the gap | ||||||
Tier 1: Preferred Generic: | $4.00(A) | $4.00(A) | n/a | $10.00(A) | $10.00(A) | n/a |
Tier 2: Generic: | $10.00(A) | $10.00(A) | n/a | $25.00(A) | $25.00(A) | n/a |
All Formulary Generic Drugs: | 51% | 51% | 51% | 51% | 51% | 51% |
All Formulary Brand-Name Drugs: | 40% | 40% | 40% | 40% | 40% | 40% |
Catastrophic Coverage Phase Cost Sharing | ||||||
Generic & Preferred Multi-Source Drugs: | The greater of 5% or $3.30 | The greater of 5% or $3.30 | ||||
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): | The greater of 5% or $8.25 | The greater of 5% or $8.25 | ||||
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. (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 HAP Senior Plus Option 3 (HMO-POS) 2017 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 |