2018 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
Senior Care Plus: Freedom Rx Plan (PPO) (H2906-007-0) Benefit Details | ||||||
This plan is available in Churchill County, NV Monthly Premium: $50.00 Rx Deductible: $0 Initial Coverage Limit: $3,750 Click on a letter below to view the Senior Care Plus: Freedom Rx Plan (PPO) 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: | $8.00 | $8.00 | n/a | $20.00 | $20.00 | n/a |
Tier 2: Generic: | $16.00 | $16.00 | n/a | $40.00 | $40.00 | n/a |
Tier 3: Preferred Brand: | $47.00 | $47.00 | n/a | $117.50 | $117.50 | n/a |
Tier 4: Non-Preferred Brand: | $100.00 | $100.00 | n/a | $250.00 | $250.00 | n/a |
Tier 5: Specialty Tier: | 33% | 33% | n/a | n/a | n/a | n/a |
Tier 6: Select Care Drugs: | $4.00 | $4.00 | n/a | $10.00 | $10.00 | n/a |
Coverage Gap (Donut Hole) Phase Cost Sharing Plan offers no Gap Coverage -- 56% Generic and 65% Brand Donut Hole Discount applies | ||||||
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 | ||||
Go to the Senior Care Plus: Freedom Rx Plan (PPO) 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 |