2018 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
Tufts Medicare Preferred HMO Saver Rx (HMO) (H2256-028-0) Benefit Details | ||||||
This plan is available in Barnstable County, MA Monthly Premium: $0.00 Rx Deductible: $400 Initial Coverage Limit: $3,750 Click on a letter below to view the Tufts Medicare Preferred HMO Saver 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 |
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Preferred Pharmacy | Standard Pharmacy | Mail- Order* | Preferred Pharmacy | Standard Pharmacy | Mail- Order* | |
Initial Deductible Phase Cost Sharing | ||||||
Tier 1: Preferred Generic: | $6.00(E) | $6.00(E) | n/a(E) | $18.00(E) | $18.00(E) | n/a(E) |
Tier 2: Generic: | $12.00(E) | $12.00(E) | n/a(E) | $36.00(E) | $36.00(E) | n/a(E) |
Tier 3: Preferred Brand: | 100% | 100% | 100% | 100% | 100% | 100% |
Tier 4: Non-Preferred Drug: | 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: | $6.00 | $6.00 | n/a | $18.00 | $18.00 | n/a |
Tier 2: Generic: | $12.00 | $12.00 | n/a | $36.00 | $36.00 | n/a |
Tier 3: Preferred Brand: | $47.00 | $47.00 | n/a | $141.00 | $141.00 | n/a |
Tier 4: Non-Preferred Drug: | $100.00 | $100.00 | n/a | $300.00 | $300.00 | n/a |
Tier 5: Specialty Tier: | 25% | 25% | n/a | n/a | n/a | 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 | ||||
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. | ||||||
Go to the Tufts Medicare Preferred HMO Saver 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 |