2018 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
AllCare Advantage Gold Plus Rx (HMO) (H3810-003-0) Benefit Details | ||||||
This plan is available in Douglas County, OR Monthly Premium: $139.40 Rx Deductible: $295 Initial Coverage Limit: $3,750 Click on a letter below to view the AllCare Advantage Gold Plus Rx (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 |
|||||
Preferred Pharmacy | Standard Pharmacy | Mail- Order* | Preferred Pharmacy | Standard Pharmacy | Mail- Order* | |
Initial Deductible Phase Cost Sharing | ||||||
Tier 1: Preferred Generic: | $5.00(E) | $5.00(E) | n/a(E) | $0.00(E) | $0.00(E) | $0.00(E) |
Tier 2: Generic: | $15.00(E) | $15.00(E) | n/a(E) | $30.00(E) | $30.00(E) | $30.00(E) |
Tier 3: Preferred Brand: | 100% | 100% | 100% | 100% | 100% | 100% |
Tier 4: Non-Preferred Brand: | 100% | 100% | 100% | 100% | 100% | 100% |
Tier 5: Specialty Tier: | 100% | 100% | 100% | 100% | 100% | 100% |
Initial Coverage Phase Cost-Sharing | ||||||
Tier 1: Preferred Generic: | $5.00 | $5.00 | n/a | $0.00 | $0.00 | $0.00 |
Tier 2: Generic: | $15.00 | $15.00 | n/a | $30.00 | $30.00 | $30.00 |
Tier 3: Preferred Brand: | $45.00 | $45.00 | n/a | $90.00 | $90.00 | $90.00 |
Tier 4: Non-Preferred Brand: | $95.00 | $95.00 | n/a | $190.00 | $190.00 | $190.00 |
Tier 5: Specialty Tier: | 25% | 25% | n/a | 25% | 25% | 25% |
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: | $10.00(A) | $10.00(A) | n/a | $20.00(A) | $20.00(A) | $20.00(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. (E) Drugs on this tier are excluded from the Initial Deductible and do not count toward meeting the deductible. (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 AllCare Advantage Gold Plus Rx (HMO) 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 |