2017 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
Platinum Blue Choice Plan with Rx (Cost) (H2461-009-0) Benefit Details | ||||||
This plan is available in Lake County, MN Monthly Premium: $110.70 Rx Deductible: $400 Initial Coverage Limit: $3,700 Click on a letter below to view the Platinum Blue Choice Plan with Rx (Cost) 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 | ||||||
This Plan Uses Lower Cost-Sharing for Preferred Pharmacies | ||||||
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 | ||||||
Tier 1: Preferred Generic: | $6.00(E) | $11.00(E) | n/a(E) | $12.00(E) | $22.00(E) | n/a(E) |
Tier 2: Generic: | $12.00(E) | $17.00(E) | n/a(E) | $24.00(E) | $34.00(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% |
Tier 6: Select Care Drugs: | $0.00(E) | $5.00(E) | n/a(E) | $0.00(E) | $10.00(E) | n/a(E) |
Initial Coverage Phase Cost-Sharing | ||||||
Tier 1: Preferred Generic: | $6.00 | $11.00 | n/a | $12.00 | $22.00 | n/a |
Tier 2: Generic: | $12.00 | $17.00 | n/a | $24.00 | $34.00 | n/a |
Tier 3: Preferred Brand: | 20% | 25% | n/a | 20% | 25% | n/a |
Tier 4: Non-Preferred Brand: | 45% | 50% | n/a | 45% | 50% | n/a |
Tier 5: Specialty Tier: | 25% | 25% | n/a | 25% | 25% | n/a |
Tier 6: Select Care Drugs: | $0.00 | $5.00 | n/a | $0.00 | $10.00 | n/a |
Coverage Gap (Donut Hole) Phase Cost Sharing Plan offers no Gap Coverage -- 49% Generic and 60% Brand Donut Hole Discount applies | ||||||
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. | ||||||
Go to the Platinum Blue Choice Plan with Rx (Cost) 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 |