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2017 Medicare Advantage Plan Prescription Drug Cost-Sharing Details
| 2017 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
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Kaiser Permanente Senior Advantage Hawaii Island (HMO) (H1230-014-0) Benefit Details 
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| This plan is available in Hawaii County, HI Monthly Premium: $194.00 Rx Deductible: $400 Initial Coverage Limit: $3,700 Click on a letter below to view the Kaiser Permanente Senior Advantage Hawaii Island (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* | |
| Initial Deductible Phase Cost Sharing | ||||||
| All Formulary Drug Tiers: | 100% | 100% | 100% | 100% | 100% | 100% |
| Initial Coverage Phase Cost-Sharing | ||||||
| Tier 1: Preferred Generic: | $4.00 | $4.00 | n/a | $12.00 | $12.00 | n/a |
| Tier 2: Generic: | $13.00 | $13.00 | n/a | $39.00 | $39.00 | n/a |
| Tier 3: Preferred Brand: | $45.00 | $45.00 | n/a | $135.00 | $135.00 | n/a |
| Tier 4: Non-Preferred Brand: | $100.00 | $100.00 | n/a | $300.00 | $300.00 | n/a |
| Tier 5: Specialty Tier: | 25% | 25% | n/a | 25% | 25% | n/a |
| Tier 6: Vaccines: | $0.00 | $0.00 | n/a | 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 Kaiser Permanente Senior Advantage Hawaii Island (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 | ||||||