2017 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
HealthPartners Freedom Ultimate with Rx (Cost) (H2462-011-0) Benefit Details | ||||||
This plan is available in Carlton County, MN Monthly Premium: $231.00 Rx Deductible: $170 Initial Coverage Limit: $3,700 Click on a letter below to view the HealthPartners Freedom Ultimate 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 | ||||||
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: | $7.00 | $7.00 | $7.00 | $21.00 | $21.00 | $14.00 |
Tier 2: Generic: | $16.00 | $16.00 | $16.00 | $48.00 | $48.00 | $32.00 |
Tier 3: Preferred Brand: | $47.00 | $47.00 | $47.00 | $141.00 | $141.00 | $94.00 |
Tier 4: Non-Preferred Brand: | $100.00 | $100.00 | $100.00 | $300.00 | $300.00 | $200.00 |
Tier 5: Specialty Tier: | 29% | 29% | 29% | n/a | n/a | 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 | ||||
Go to the HealthPartners Freedom Ultimate 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 |