2017 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
MCS Classicare InteliCare (HMO) (H5577-005-0) Benefit Details | ||||||
This plan is available in Coamo County, PR Monthly Premium: $0.00 Rx Deductible: $0 Initial Coverage Limit: $3,700 Click on a letter below to view the MCS Classicare InteliCare (HMO) 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: | $4.00 | $4.00 | n/a | $12.00 | $12.00 | n/a |
Tier 2: Generic: | $8.00 | $8.00 | n/a | $24.00 | $24.00 | n/a |
Tier 3: Preferred Brand: | $35.00 | $35.00 | n/a | $105.00 | $105.00 | n/a |
Tier 4: Non-Preferred Brand: | $55.00 | $55.00 | n/a | $165.00 | $165.00 | n/a |
Tier 5: Specialty Tier: | 33% | 33% | n/a | n/a | n/a | n/a |
Tier 6: Select Care Drugs: | $2.00 | $2.00 | n/a | $6.00 | $6.00 | 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 | $12.00(A) | $12.00(A) | n/a |
Tier 2: Generic: | $8.00(A) | $8.00(A) | n/a | $24.00(A) | $24.00(A) | n/a |
Tier 6: Select Care Drugs: | $2.00(A) | $2.00(A) | n/a | $6.00(A) | $6.00(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. (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 MCS Classicare InteliCare (HMO) 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 |