2017 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
Erickson Advantage Guardian (HMO-POS SNP) (H5652-003-0) Benefit Details | ||||||
This plan is available in Douglas County, MD Monthly Premium: $35.80 Rx Deductible: $0 Initial Coverage Limit: $3,700 Click on a letter below to view the Erickson Advantage Guardian (HMO-POS SNP) 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: | $0.00 | $0.00 | n/a | $0.00 | $0.00 | $0.00 |
Tier 2: Generic: | $0.00 | $0.00 | n/a | $0.00 | $0.00 | $0.00 |
Tier 3: Preferred Brand: | $28.00 | $28.00 | n/a | $84.00 | $84.00 | $74.00 |
Tier 4: Non-Preferred Drug: | $70.00 | $70.00 | n/a | $210.00 | $210.00 | $200.00 |
Tier 5: Specialty Tier: | 33% | 33% | n/a | 33% | 33% | 33% |
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 Erickson Advantage Guardian (HMO-POS SNP) 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 |