2018 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
HealthPartners Freedom Ultimate with Enhanced Rx (Cost) (H2462-012-0) Benefit Details | ||||||
This plan is available in Murray County, MN Monthly Premium: $375.90 Rx Deductible: $115 Initial Coverage Limit: $3,750 Click on a letter below to view the HealthPartners Freedom Ultimate with Enhanced 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: | $5.00 | $5.00 | $5.00 | $15.00 | $15.00 | $10.00 |
Tier 2: Generic: | $14.00 | $14.00 | $14.00 | $42.00 | $42.00 | $28.00 |
Tier 3: Preferred Brand: | $47.00 | $47.00 | $47.00 | $94.00 | $94.00 | $94.00 |
Tier 4: Non-Preferred Drug: | 50% | 50% | 50% | 50% | 50% | 50% |
Tier 5: Specialty Tier: | 29% | 29% | 29% | n/a | n/a | n/a |
Coverage Gap (Donut Hole) Phase Cost Sharing 56% Generic and 65% Brand Donut Hole Discount applies to all drugs even those with coverage in the gap | ||||||
Tier 1: Preferred Generic: | $5.00(A) | $5.00(A) | $5.00(A) | $15.00(A) | $15.00(A) | $10.00(A) |
Tier 2: Generic: | $14.00(A) | $14.00(A) | $14.00(A) | $42.00(A) | $42.00(A) | $28.00(A) |
Tier 3: Preferred Brand: | 24%(A) | 24%(A) | 24%(A) | 24%(A) | 24%(A) | 24%(A) |
All Formulary Generic Drugs: | 44% | 44% | 44% | 44% | 44% | 44% |
All Formulary Brand-Name Drugs: | 35% | 35% | 35% | 35% | 35% | 35% |
Catastrophic Coverage Phase Cost Sharing | ||||||
Generic & Preferred Multi-Source Drugs: | The greater of 5% or $3.35 | The greater of 5% or $3.35 | ||||
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): | The greater of 5% or $8.35 | The greater of 5% or $8.35 | ||||
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 HealthPartners Freedom Ultimate with Enhanced Rx (Cost) 2018 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 |